Monthly Archives: October 2012

The Fall. Part 9.

28th June

We rose early yesterday morning, as has become our habit on driving days, and pulled away from our charming Alpine retreat at about 5am.  Coming down off the side of the hill where our camp had been we found ourselves completely alone on the wide road at the base of the valley which would take us out of town and back to Route 10. Alone, quiet, and quite beautiful, as the sun started to rise and the valley floor and surrounding hills slowly morphed from brown to beige to tan to yellow to orange. By the time we reached the interstate the sky was cobalt blue and the earth returned to its familiar burnt red. Before we reached the interstate, though, came a nice Texas moment. A UFO, or what appeared to be one, floated up ahead of us. With no one else around and a completely empty skyline, this white roundish oval object just seemed to be suspended, not moving, not apparently attached to anything, it looked like a giant balloon that had escaped a child’s grasp. Pen took several photos and was for all the world convinced that we were in the company of extra terrestrials. My best guess was some kind of weather balloon. Time to get out of hill country!

As the day warmed up the scenery became duller – on the interstate with only lorries for company, thundering towards El Paso, which we were to skirt diagonally right of, taking the road north about 20 miles short of the border town, which would lead us up into New Mexico. Nothing particularly eventful. The nearer we got to El Paso the busier the road. An ill advised breakfast stop at a truly horrible retail park and then we were heading north, crossing the state border at about 9am. Seemed to have taken a very long time and still only about half way through. Still, a new state and a new horizon. The earth seemed to change colour almost immediately – which I realise now might have reflected nothing more than our changing position relative to the sun – now losing the angry red and brown replaced by an almost mustard yellow earth and pastel pink rock. The road too was considerably more interesting; what seemed like an endless series of quite large rolling peaks and troughs, on the way down I would have to break to keep the RV below 80 on momentum alone, then crawl up the opposite side, sometimes doing as little as 40 by the next summit. It was surprisingly extreme, and when the wind started to gust, a little unnerving.

We stopped for lunch in the car park of a Millies or Mollies or some such, and Pen cooked Mexican, which she is becoming pretty bloody good at, armed with an array of spices we’ve been buying en route. Although there had been a down to go with every up of the road we definitely felt like we were gaining elevation and this would continue after lunch. We stopped again briefly for gas, while I was filling the car Pen was inspecting one of numerous chilli stands and came back to the RV with a huge hanging bunch of dried chilli. They were quite sweet, almost chocolatey, with a slightly burnt, tobacco-like aftertaste. Really good.

An hour or so later and we found ourselves up on a kind of ridge with desert valleys on either side and almost no settlement at all, apart from the ubiquitous roadside service trade of diners, motels, and Dunkin Donuts. Then the sprawl of Albuquerque, looked pretty unpleasant from the road, all flashing neon and the road became a sea of lane-changing impatient drivers – so stark the contrast between rural and urban traffic moods. We continued climbing past Albuquerque and with quite strong wind gusting was actually pretty alarming at times, the RV lurching from side to side with each gust, and what felt like a higher, narrower ridge to stay on.

Not long after though we came over what felt like the ‘top’, and there were the suburbs of Santa Fe. Having read so much about the old fashioned beauty of the place I was a bit miffed to find the ‘burbs like any other – big roads, smelly, noisy, characterless. We soon found our new campsite to be all these things as well – though perfectly friendly and functional for it. Now past 3pm and I was pretty knackered, but, there we were in a new city and pretty restless with it, so we jumped on a bus to town and set about exploring.

Santa Fe – once you get into the city proper – is as everyone describes; an arty little piece of the past preserved through strict building regulations requiring everything to be built in the traditional adobe style. Although the newer stuff is not actually made out of mud and leftovers, but it still looks the part, and the untrained eye will not be able tell palace from car park. Perhaps it was our tiredness, but we couldn’t quite make sense of it at first, it felt a little contrived, though fascinating at the same time and with endless little boutiques and crafty places to explore the next day. In the end we plumped for a very nice early evening meal, contemporary Tex-Mex, and a couple of beers, and then headed back to the RV for well earned sleep.

Woke pretty early next morning and headed straight for town – spotted Wholefoods on the way and did a stock up on way back out, lots of new local beer to try – yummy. We had brunch in town – Huevos Rancheros – eggs in spicy tomato sauce with various kinds of beans, really really good, then we went on the tourist trail – cathedral, Native American Art Gallery, and the Palace of the Ambassadors, where we learnt a little of the area’s turbulent history – though, in all honesty, the guide was pretty crap. Still, I discovered that the version of the Lincoln cattle war that I had got via the first Young Guns film was surprisingly accurate – or at least it matched the version given in the museum. Unfortunately the Native American Art gallery was closed, real shame, had been looking forward to it. However, outside the Ambassadors were a troupe of street sellers with handmade Native American jewellery, wraps, charms and rugs. According to all the guidebooks this was the place to buy in Santa Fe, and on the spur of the moment we decided to buy our wedding rings here, after much deliberation, choosing matching silver rings with inscriptions which symbolised life, truth, and eternity – seemed pretty appropriate – and we were much happier with them than the ones we had chosen in rather a hurry before leaving England.

So, I’m now sitting back in the RV, enjoying a refreshing local pale ale, writing my journal and planning tomorrow’s route. I keep changing my mind over it. The destination is Grand Canyon (very exciting!) and it is only about 5 hours away, so I figure a little detour is in order, but can’t decide between Sedona, Arizona, which was recommended by our scootering friends in New Orleans, or, a country route through some of the villages around Santa Fe, taking a quieter route through more unknown territory than the interstate. There’s a cheesy bonus with the latter, which is the four state monument, where you can simultaneously stand in Colorado, Arizona, Utah, and New Mexico. Corny but might just swing it! The utter beauty of this trip is that we can just pick and choose as we feel and be pretty sure of something magical around the corner.

Whenever I’ve not been exploring or map consulting I’ve been flying through ‘On the Road’, it’s fantastic, the ultimate narrative for this kind of journey, and seems to be reinforcing the sense that we can just do as we please and go entirely on impulse.

So, back into town tonight for a much talked about restaurant – the food here is fab – then back to the RV for a relatively early night before back on the road tomorrow.

Life is pretty damn beautiful. 

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Small Change/Big Change

This post presents a response to my last post, which talked about routines, and I think probably gave them a little bit of a hard time. Yes, they can be a little dehumanising, and we can be far too dependent on them, and external agencies can use our patterned behaviour against us…but, they are also very powerful little strategies which can be put to good use. If we use them reflectively, perhaps we can avoid many of the pitfalls I talked about previously.

One of the things I have come to learn about critique in general is that it feels a bit disingenuous to simply stand at the sidelines pointing out all the implications and consequences of everyone else’s action. At some point you have to get your own hands dirty, whether that be making recommendations to practitioners, contributing to policy debates, or even just having an honest conversation with someone you’ve done some research with.

I don’t know if i’ll ever find it easy – nailing my colours to the mast, while simultaneously being able to see the potential problems with each new solution. Nevertheless, it is necessary if you wish to make a contribution to a debate, if you wish to engage with practitioners and policy makers in their languages, and if you wish to have some kind of impact. Bringing about change in practice is one of the biggest challenges we face in our work. So often, the change you really want to be able to make is transformational, not this piecemeal, do things slightly differently, change one or two procedures, but the big, system changing, relation changing, heavy change. I don’t know whether lots of small changes add up to a big change in institutional terms. I think in some cases they can do. After all one of the greatest sources of power is alliance, so collecting enough small things together might prompt change in much bigger things.

I used to have a job with the National Institute of Health and Clinical Excellence (NICE). They produce guidelines which are non-statutory but make up the official benchmarking for clinical practice in the NHS. I was employed by one of the NICE guideline development groups as a service user representative. This was never a role I managed to find any great comfort with. Some of the reasons for this was to do with my own hang ups about what or who I was supposed to be representing, and what exactly it was that made me representative of a particular group. But all sorts of other things were just to do with the a priori constraints that existed and limited the possibilities that could be achieved through such a guideline. For example, when making assessments about which treatments to recommend for particular conditions, we were constrained by the existing health technology assessments, which used a health economics measure of efficacy called a QUALY. Basically, this is a numeric tool combining the cost of a treatment with its reported improvements of quality of life. We had the calculation and its method explained to us – it was problematic to say the least. QUALYs are seen as significant to the fourth decimal point, and yet the calculation that goes into them is hopelessly vague and subjective. But regardless of how many of the group offered their own anecdotal best practice, if it did not fit the QUALY hierarchy then it could not be recommended.

And yet, there were things about the NICE process where there was a certain amount of compromise available between the group of individuals producing the guideline, and the institutional codes which constrained us. We managed to persuade the college that was funding the guideline to commission some primary research the analysis of which was included in the guideline. This is the first time that this has ever been the case with a guideline, which ordinarily is more like a systematic review of existing research. I think it strengthened the guideline greatly, made it appear more human, and will have given cause to stop and reflect for any practitioner reading it. I suppose that this was a fairly small, but nevertheless significant change that we prompted, and I suppose if it became the norm within a guideline process then that could be considered a bigger change. Yet, there were many accepted methods and languages that we found no give in at all.

I’m approaching the stage in my current project where we will be required to write a report back to the funders, including our recommendations. Research recommendations are often the least interesting bit of a report. They can be so dry, stripped of life, taken out of context, superficial, preachy and obvious sounding. You can imagine people reading them and going ‘duh! I already know that!’, and yet they are difficult to flesh out, give context too, make thicker, because they are intended to be snappy, direct, practice focussed, headlines.

Another project I am involved in found a creative solution to this issue. We wrote the report in as ‘lively’ style as we felt able, nevertheless we had a huge amount of really rich research material that would and could never make it into this rather dry 40,000 word document. So, the PI decided to use the remaining dissemination budget to commission a writer to write a script based on our fieldnotes. This had never been a stated intention of the project, when we were researching it we never had any sense that our work was going to be dramatised – and thus we never ‘went looking for’ dramatic moments. It has been a fascinating process to be involved in though.

Roughly two years later the script has been written, workshopped, well received by stakeholders, and we are now working towards a full production of the play in June 2013. One of the most exciting things to have happened is that the healthcare trust with whom we conducted the original research have remained engaged in this unexpected follow-up – to the extent that they and two other trusts in the area have already reserved 1000 seats across 12 performances of the play for their staff to attend. This feels like double impact – both a novel and creative means to disseminate research findings, and a largely new theatre audience, drawn from some of the most poorly paid frontline staff in the NHS. That three healthcare trusts – with all the recent policy flux and budget slashing – are prepared to release something like 150 staff at a time to come and see a piece of theatre…that certainly defies expectation, perhaps represents a certain amount of transformation in itself, and if we are able to present something to challenge as well as entertain then the ripples could spread much further.

I’ll certainly be blogging more on this process, so watch this space.