Edward Andersson reflects on a little understood opening for citizen and patient engagement in the NHS.
The NHS is going through a dramatic time of change. The Health service is of course one of the areas of the public sector most prone to reforms and changes, often to the frustration of staff. One of the more hopeful developments at the current time is a push for more transparency and openness.
Traditionally the NHS has been accountable to Whitehall rather than the public. Doctors and other health professionals have been accountable to their professional bodies, rather than patients.
The process of ‘revalidation’ represents one of the most interesting opportunities for patient influence. It is not widely understood, but I believe it may mark the beginning for something significant. So what is revalidation?
It is, simply put, a new process by which licensed doctors regularly need to demonstrate that they are fit to practice. The process for each individual doctor happens every five years and started in December 2012. From Involve’s perspective the most interesting part is that one of the six forms of information required as part of the revalidation process is feedback from patients. Of course many good doctors have been gathering patient feedback for many years as part of their daily work; but patient feedback is now part of a legally mandated process. We mustn’t get over excited –the GMC guidelines suggest that as little as 34 pieces of patient feedback in the form of questionnaires would be enough –not much over five years!
Still, revalidation represents an opening, even though it may seem insufficient. Revalidation is supported by groups such as National Voices, the Patients Association and the National Association for Patient Participation, who state “The scope and frequency of patient feedback in the initial revalidation model is, in our view, too limited, but it does establish the principle of patient feedback in the process”. (PDF document)
From my perspective one of the key limitations of revalidation as it stands is that it relies heavily on formal questionnaires. These aim to track how well the doctor assessed the patient’s medical condition, listened to them and involved them in any decisions about their treatment. This is all useful, but my experience tells me that questionnaires often fail to capture vital nuances. It will be all too easy for the patient feedback aspects to become another exercise of box ticking.
Involve is currently working with Shared Services part of (Health Education England) to look at more innovative ways to gather feedback as part of the revalidation process. We’re looking at applied theatre based approaches and other more creative approaches which allow patients who struggle to express themselves in writing to take part, and allow more qualitative nuances of care to be explored.
Revalidation represents a very important opening for patient voices –while on its own it’s not enough, it could provide a vital narrative for shifting both thinking and practice about patients in being there to be consulted with, to one of ongoing active engagement and involvement in holding health and related services to account. If you know of good examples of innovation around revalidation do get in touch, particularly if you know of good creative approaches.
Involve and the Professional Support Unit (PSU) (part of Shared Services of Health Education England) have come together as partners to develop a programme of work around improving health and engagement practices, with a strong focus on developing the role and voice of service users (includes patients, the public, carers and other community-based groups). Public and patient involvement has a considerable history in the UK and beyond. For Involve, the project marks an interesting exploration of the role of co-production in changing professional education, research, and services. It also highlights the importance of arts based approaches in participation. For PSU, the interest is in developing more creative approaches to improving communication and the use of information through dialogue between professionals, service user communities and organisations, to achieve better health outcomes that are more meaningful for the service users. This joint project is targeted at professionals and teams working in health related organisations and projects (including their patients, carers, and service users) to address health issues. This project is about helping people work together to improve the quality of communication and information. We will do so through creative dialogue driven approaches to learning for changing health provision, policy, research and, or professional practices, delivered through a series of participatory workshops.
Co-productive learning has been a growing field of practice over the last few years. As an ‘asset-based approach’ it works on the assumption that we all bring a set of valuable experiences, expertise and skills which can be developed and built upon to help improve our health, and the health of others. Such learning recognises all forms of expertise, but the process of creating meaningful dialogue between people with these different types of expertise can be challenging, for example where issues of power relationships need to be recognised.
Our project “Developing and Learning Together for Achieving Better Health through Dialogue” will use workshop sessions to explore and demonstrate innovative ways of co-producing learning together. It will draw on theory and practices from applied theatre, community development and adult education to make it easy and fun and in ways that mean you can start to make changes sooner, and not just later.
Involve’s role will be to lead on the development of an online resource based on these workshops, working with its other partners, workshop participants and wider network members, who will also provide substantive input. The resource will contain:
Involve and Local Government Improvement and Development have recently published ‘Not another Consultation' -a new guide on informal engagement in the health sector. It outlines practical ways of engaging with local people in ways which are fun and creative.
We worry a lot about the 'usual suspects'; I'd argue we should worry more about the 'usual methods' which we use out of reflex. Public meetings, online consultation documents and other 'traditional' methods are useful -in some contexts and for some people. What the document proposes is to broaden the range of tools we use to include approaches which feel more like games than social research.
I think there are three strong reasons for making engagement more fun:
1. Firstly, it'll help you broaden your participant profile, reaching people who will never come along if the process seems dry and dull. 2. Secondly, people will enjoy the sessions more, so they're more likely to come back, recommend it to friends and they'll contribute more creatively. As a result you may get more from the meetings. 3. Finally, these types of events tend to be more enjoyable for the organiser as well.
So if there are so many compelling reasons why don't more public bodies embrace a more creative and fun approach to consultation and engagement? I think the answer partly lies in organisational culture. 'Fun' feels like a very foreign concept in a professional world and so the idea that colourful crayons, funny shaped Post Its and glitter sticks might be legitimate consultation expenses might be met with some resistance.
What I have found is that you can get people who self-identify as 'serious' and 'professional' to do things that are creative and enjoyable but you need to frame it in the right way. Approaches such as World Cafe (where you draw on the table cloths) and Open Space (where there is no agenda) tend to be resisted by many professionals and doubly so if we use the ‘fluffy' language which tends to surround these methods. Try selling the ideas of 'hospitable space', 'Native American talking objects' and 'whenever it starts is the right time' (to name a few examples) to sceptical bureaucrats!
Instead I've had better results where I've focussed on emphasising that these methods have been used repeatedly by big companies (IBM, Shell, Toyota), by big institutions (World Economic Forum, NHS trusts etc) and on the research which shows that more creative approaches are good at enhancing creative solutions.
Of course ‘fun' isn't risk free; one of the biggest risks is of seeming insensitive or flippant towards your participants. I've seen cases where project staff were very excited about new voting pads and wanted to do a quiz about what people liked about the neighbourhood. Normally that would be a good idea. The problem was the local people were more interested in talking about cuts and their disappointment towards the council and so the quiz came across as a diversionary exercise. It is far easier to do something 'fun' around an upbeat topic than it is about something contentious (such as cuts). In these latter cases we might need to settle for 'respectful' consultation.
There will be scepticism towards informal engagement; this is after all a new way of working. We need to keep chipping away at the attitude that engagement must be worthy and consultation must be like pulling teeth or else it lack rigour and is not good evidence. Our participants deserve better than this and so do we.
This blog is a repository for posts I have made over the years at Involve as well as more personal reflections.