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.

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