A discussion paper



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CITIZEN CENTRED POLICY FORMULATION

IN WELSH PUBLIC SERVICES?
A DISCUSSION PAPER
THE USE OF CITIZEN STORIES IN POLICY DEVELOPMENT

PURPOSE
This discussion paper has been prepared by a Connect 4 Cymru cohort considering Health Reconfiguration. Building on recent work undertaken by Public Service Management Wales, and the Welsh Institute of Health & Social Care in Wales, it has been developed to aid thinking on the use of storytelling to inform policy development in the public sector in Wales.
The following groups may find it of particular use :


  • Service providers

  • Commissioners of services

  • Recipients of services

  • Service/System change agents

  • Those involved in the development of policy


WHAT IS STORYTELLING?
Storytelling has existed for time immemorial as a means of conveying information about mankind and ones kith and kin (and enemies) and has its place in the evolution of culture. It is part of the fabric of social life, and increasingly a legitimised method used to collect experiences and views related to public services. We tell stories formally and informally, to convey our perspective of the world and what it is to be human, to share our experiences and to communicate our dreams and our disappointments. We tell stories as individuals, in groups and as communities. We use many means to convey our stories – consider the role of the minstrel in mediaeval times or Shakespeare who had a particular way of conveying contemporary culture through theatre. In earlier times cave drawings were the tabloids or even the broad sheets of the time.

Every one of us is a storyteller, and each of us has the ability to listen, to hear and respond to the stories of others whether at home, at work or at play. Stories are increasingly gaining a respected place in the scientific understanding of what it is to be human from a phenomenological (lived and felt experience) perspective. Stories enliven and inform us of real people and their lived experiences at a grass roots level.

Stories can help service recipients and staff to make sense of what is happening all around them on an everyday basis. They can help develop, and inspire, solutions as well as exposing and exploring problems and identifying needs. Within public service developments there has been an emphasis on analytical and numerical means of collecting information, and less focus on the actual experience of the service users. However, stories can act as a bridge between an objective, intellectual way of gathering information and a more personally meaningful and subjective experience of a situation. It is often the latter that will add depth to lead to service improvements and change because it is rooted in what is viewed as important and memorable. This paper does not set stories as a panacea for all, it does indeed recognise the inherent limitations of using storytelling as a means of measuring and evaluating services, however it does advocate the use of stories as a method to enhance and strengthen citizen engagement to inform service delivery.

STANDING ON THE SHOULDERS OF GIANTS

Passionate supporters of storytelling, including academics such as Professor Geoff Mead from the University of Bath, convinced the C4C cohort that understanding and tapping into the power of stories was essential for leaders and managers in all services in order to appreciate the personal impact of decisions, affecting service delivery. As Ken Jarrold, a former Strategic Health Authority Chief Executive articulated in 2007 ‘Stories can warn, shock, energise and inspire and are a spur to action’


Other serious researchers into the education of doctors advocate storytelling as a means of getting closer to the real issues in the field of medicine (see for example Alan Bleakley’s work) (2005).

Professor Aidan Haligan, former Deputy Chief Medical Officer for England, and a keen advocate of storytelling in the NHS, provides a wonderful set of soundbites in his passion for storytelling:

The brain sees what the heart allows it to feel”

Nothing matters until it is personal.”
THE USE OF STORYTELLING IN WALES
Storytelling appears to have made a strong revival in Public Services in Wales in the past two years, with many influential public sector organisations, for example, Public Services Management Wales and the Welsh Institute for Health & Social Care, heralding the use of qualitative and participative methods of enquiry to place the citizen at the real heart of public sector services.
Storytelling can be a powerful force in changing behaviour and culture, due to the ability of stories to add an emotional dimension to decision-making and change. There are an increasing number of examples where story telling has been used to influence service change and patient experience in Wales. Some of these are displayed in Box 1.

Box 1. Examples of Storytelling in Public Services In Wales


Example

Organisation







Effecting real change – patient led safety improvements

Carers clinic in the Stroke Unit at Neville Hall Hospital in Abergavenny

Discovery Interviews

South East Wales Cardiac Network

Understanding Real Life Genetics web based project

University of Glamorgan.

Assessment procedures within Adult Mental Health


As part of the Care Programme Approach – many Trusts are inviting service users to tell their stories as part of an emphasis on recovery

Breaking Barriers Project

Established charity working on community change programmes

Development of integrated health and social care centre in the North of Caerphilly County Borough

Service change at a community level

Hospital Discharge Scheme Case Studies

Age Concern Swansea

Neurological alliance Wrexham

Stories from patients and carers being used for CPD for GPs

Sexual health stories

BME

Service User Empowerment training

The SURE Group mental health service users in Rhondda Cynon Taff

These examples illustrate where storytelling has been, or is being, used to effect change. This change has predominantly been at an operational level, and led to better experiences for individual service recipients. There is however undoubtedly more potential to be realised in the use of stories at a community, regional and National level in Public Service Wales.


STORYTELLING WITHIN THE ‘MAKING THE CONNECTIONS’ CONTEXT

The Welsh Assembly Government vision for Public Services “Making The Connections”, strongly places the citizen at the centre of policy, services and evaluation, with localism a central feature of current reconfiguration plans. Citizens don’t always see themselves as service users, but as individuals, families and communities. Their stories are real, and based on experience, perception and expectation. Storytelling offers a strong qualitative approach to distilling key messages about life in Wales, and through this approach there are lessons to be learned about the way we plan, organise and deliver services for the population, told through words and anecdotes which give life and meaning to everyday interactions with the services we provide.

Like life, the stories are often multi-faceted, not particular to one area, and show the complexity of services provided by many often to the same individual. Through the lens of those watching, we can learn far more about ways to not only make the connections, but also to use them and strengthen them.
CAN WE ACHIEVE A HIGHER LEVEL OF INVOLVEMENT ?
In the Welsh Assembly Government’s commitment to enabling the citizen to be at the centre of public services, there are a number of opportunities where stories could be used to better effect and, indeed, be used to add value and depth to the formulation of public sector policy:


  • to enable a wider sharing of experience and good practice,

  • to identify themes and recurrent issues requiring service change and improvement,

  • as an important element of academic research and organisational learning,

  • as an opportunity to improve communication and encourage public participation and engagement

  • as a way of putting the citizen at the centre of change and decision making

  • to influence strategy and policy

  • to gain a greater sense of what is important to the Welsh public


CITIZEN STORIES IN THE POLICY ARENA
The key challenge for policy makers in public services in Wales is enabling citizen influence in the formulation and execution of public policy. A suitable balance between public and professional view needs to be established, and additional ways of engaging citizens at a policy level found. Exploring people’s localised perceptions and experiences can help unlock and inspire local solutions within a broad national policy context .

The context within which the story is told is also important, and consideration therefore needs to be given to the cultural setting of the story-teller, aiming to ensure rigour and integrity is maintained, to reduce confusion and mis-understanding. Story-telling may offer a more acceptable and inclusive approach to those groups of people who are vulnerable or marginalized and at times hard to reach because of cultural differences.

Moreover mechanisms to enable the systematic collection of stories from an individual to a community level, to aggregate key messages, and triangulate those messages with other stakeholder experience is essential.
The route to inform policy could be described as follows:



Recommendations from this work are therefore aligned with these areas:
RECOMMENDATIONS
On the basis of our research and findings, we make the following recommendations to bring story telling into the policy making process in public service delivery in Wales. These recommendations recognise the importance of capturing the context of the story teller, protecting integrity and valuing diversity :


  • Collecting stories at an individual/community level




  • Pilot the potential to develop an all Wales story bank hosted by the Welsh Institute of Health and Social Care

  • Pilot Local Service Boards as a bridge between citizen influence at a local level, and influencing policy at a National level

  • Develop a skills package for capturing storytelling




  • Distilling/Triangulating key messages




  • Develop a community/organisational approach to understanding stories in a way which avoids distortion, filters information whilst maintaining integrity.

  • Seek to develop existing mechanisms to spot recurring messages and identify trends in stories and build evidence

  • Commission further research on ensuring scientific rigour in regard to the methodology whilst at the same time protecting the soul of the stories.




  • Determining the route to inform policy


  • Strengthen the route to informing policy (eg effective policy gateway)

  • Pilot use of LSB as co-ordinating mechanism of local stories, and policy formulation

  • Pilot the use of storytelling to test emerging trends/anecdotes

  • Use of Champions for story telling eg Board members, Councillors, Commissioner for Older People and Children.




  • Policy formulation




  • Enable a more inclusive and transparent approach to policy formulation for example :




    • Broaden the role of Community Health Councils in informing health policy (e.g. use of trends in complaints and comments etc)

    • Strengthen utilisation of citizen panels in policy testing

    • Strengthen utilisation of community councils to consult and test policy .

    • Strengthen citizen juries in policy formulation



  • Policy Implementation




  • Develop methodologies to evaluate the application and impact of storytelling at an operational level

  • Use storytelling to strengthen implementation guidance (in addition to case illustrations)

  • Use storytelling in its different media to introduce guidance (e.g. when launching a Policy Implementation Guidance – use video to emphasise the need to operationalise policy)

  • Use story-telling to adapt national policy to local implementation




  • Policy Evaluation (Feedback loop)




  • How do we know we have been successful? Gain stories to assess next strategy iteration (i.e. what worked well, what would be better?)
  • How can we test public acceptability and local alignment ?

Since the inception of this project, it has become apparent that story-telling could effectively be used as a tool in gauging user and staff perception of major organisational change within the public sector, for example the current reconfiguration of NHS Wales. To commence this process, the C4C cohort at its shared event, sought views of other public sector managers of the NHS, in 6 words, a flavour of the responses is attached at annex A.


CONCLUSION
The use of story-telling is growing in popularity in the Welsh Public services, as a means of enabling true experiences and expressed need to be incorporated into both day to day and longer term decisions. The use of story-telling can be used at an individual or collective level, and as such there are opportunities to harness the experiences of the story-tellers in both small service change or influencing, and evaluating national policy. Story-telling is a useful tool, however requires integrity and rigour to ensure the meaning of the story is not lost, and that citizens voices are truly integral to public services in Wales.


Bibliography

Bleakley, A. 2005. Stories as data, data as stories: Making sense of narrative inquiry in clinical education. Medical Education. 2005:39 pp. 534 – 540.


Case Studies: including Edwards, R.T. Confessions of a Reconstructed Health Economist.
Centre for Action Research in Professional Practice. A Layperson’s Guide to Co-operative Inquiry. Bath University. [Online] http://www.bath.ac.uk/carpp/publications/coop_inquiry.html

Farrington-Douglas, J. & Brooks, R. 2007. The Future Hospital. The progressive case for change. Institute for Public Policy Research. January 2007.

Farrington-Douglas, J. & Brooks, R. 2007. The Future Hospital. The politics of change. Institute for Public Policy Research. May 2007.

Heron, J. and Reason, P. 2000. The Practice of Co-operative Inquiry: Research ‘with’ rather than ‘on’ people. [online article] http://www.human-inquiry.com/ciacadem.htm

Jarrold, K. 2007. Ken Jarrold on improving the NHS through story telling. Health Service Journal. (17th December 2007) [Accessed online] http://www.hsj.co.uk/workinglives/columnists/2007/11/ken_jarrold_on_improving_services_through_story_telling.html


Jones, K. 2002. The turn to a narrative knowing of persons: One method explored. Nursing Times Research: 8(1), pp. 60 - 71.


Jones, K. 2005. The Art of Collaborative Storytelling: arts-based representations of narrative contexts. Draft Article for the International Sociology Association Research Committee Newsletter, Summer 2005.
Mead, G. 2007. Telling Stories: Realising the Power of Narrative Leadership. Catalyst. Issue 6. Spring 2007. pp. 4 – 5.

Meyerson, D.E & Scully, M.A. 1995. Tempered Radicalism and the Politics of Ambivalence and Change. Organization Science. Vol.6, No. 5. Sept - Oct 1995. pp. 585 - 600


Popay, J. 2006. Community Engagement for Health Improvement:

questions of definition, outcomes and evaluation. A background paper prepared for NICE by Professor Jennie Popay. March 31st 2006.
Public Sector Management Wales. Telling Stories. Developing organisational narratives to support the process of change. Sowing Seeds Publication Series. PSMW.

Public Sector Management Wales. Engaging the Workforce. Engaging the Welsh Public Service Workforce. Sowing Seeds Publication Series. PSMW.

Rooke, D. 2001. Organisational Transformation requires the presence of leaders who are Strategists and Magicians. First published in Organisations and People, Vol 4.3 (1997). Amended October 2001.
Snowden. D,J. and Boone, M,E. 2007. A Leader’s Framework for Decision Making. Harvard Business Review (November 2007). pp. 69 - 76
Swansea NHS Trust. Guidelines for Staff Undertaking Patient Stories
Welsh Assembly Government. 2005. Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century.
Welsh Assembly Government. 2006. Beyond Boundaries. Citizen-Centred Local Services for Wales. 2006.
Welsh Assembly Government. 2006. Making the Connections – Delivering beyond Boundaries: Transforming Public Services in Wales. November 2006.

Produced by a Connect for Cymru (C4C) cohort considering health reconfiguration

Specific enquiry area was:
- What can we learn from patient stories or case studies (both positive and negative) of their personal experiences of the interface across health and other care sectors, in relation to patient discharge, in order that we :
- distil key messages and feedback to strategic decision makers and policy leads in Wales/Cymru
- reflect on current mechanisms that inform strategic decision making and how they can further be improved

- make recommendations to inform the process of re- configuration of health service in Wales/Cymru

The group comprised Barbara Bowness, Nicola Davies, Amanda Hall, Claire Harding, David Murphy, Clive Powlson, Jenny Sanger, Alex Thomas and Nicola Williams. Contact details:

Barbara.bowness@nliah.wales.nhs.uk

Nicola.davies@rhonddacynontafflhb.wales.nhs.uk



amanda.hall@swansea-tr.wales.nhs.uk

Jenny.Sanger@Wales.GSI.Gov.UK

Claire.harding@caerphillylhb.wales.nhs.uk

Alex.thomas@bromor-tr.wales.nhs.uk

Clive.powlson@dvla.gsi.gov.uk


Facilitators were Arthur Turner & Kay Howells


Specific thanks are extended to Neil Wooding, Marcus Longley, Bob Hudson, Helen Howson, Chris Riley, Liz Rees and Christine Wilson for their support and advice in the development of this enquiry. And to Steve Hall for the front cover design.





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