What is meaningful engagement? Experiences at a conference

I recently attended the Health Service Journal conference titled Achieving Meaningful Public Engagement in London on the 12th March. It has been a while since I have been to a conference. I arrive from Manchester after a night of storms and high winds that had delayed my train.

It was an interesting and varied day. I appreciated the time to think and reflect without the responsibility for leading or speaking at an event.

The stand out presentation for me was by Dr. Jeff French on social marketing - debunking the myth that this has anything to do with advertising or spin. The essential point was that the main thing we can learn from a marketing approach is understanding peoples’ insight and what is important to them - and then apply this to social good as opposed to economic good which is the traditional territory of marketing.

I noticed a real difference in the words and language used by different speakers. It illustrated for me the gap between the mechanical approach to engagement and the more bottom-up, user focused approach. Some of the speakers presented engagement as a technical process - it felt cold and separate from the real world of peoples’ lives. It was a relief in the afternoon when speakers started talking about personal journeys, trust and appreciating different world views. I also feel ambivalent when engagement is presented as an industrial process that can be replicated, scaled-up and shipped out to communities. Surely engagement needs to be more nuanced and personalised with a real appreciation of the communities and local people where it is happening.

There was an interesting debate around the metrics of engagement and how we can find ways to measure and quantify the value of this work. To argue for more resources and investment in engagement we are going to have to demonstrate it’s benefits and how these represent value for time and money invested. The challenge for me is how we do this in a way that retains the richness and uniqueness of peoples’ lives - I fear that some metric models might simply reduce our work to numbers and statistics that alienate our stakeholders and mask local change. More work is needed in this area - and more creative thinking that can draw on metrics that use non-traditional methods such as art, drama, visual and experiential data.

The conference talked a lot about meaningful engagement. But what does this mean - and meaningful to who? The local people or the organisations doing the engagement. Organisations who often have a set idea of the data and contributions they are looking for. That is not to say that organisation pre-decide the outcomes of engagement. Simply that by having the power to set the approach and boundaries of any engagement activity you are immediately influencing and to some extent controlling the process. What if those who are being engaged have an entirely different vision or agenda to the engagers? What if the topic of engagement actually bears very little relation to the day-to-day lives of local people? And where are the opportunities for local people to be the engagers - with the time, money and authority to take control of the engagement process and start to describe agendas from their own perspective.

It is important that engagement does not get reduced to another tactic or prescription that the powerful offer to the less powerful. I think there needs to be space in conferences like this one for organisations to reflect on their power and their abilities, whatever their intentions, to do harm as well as good. Engagement is not easy - it should be a constant process of dialogue and reflection. Organisations need 'critical friends' in the community who can challenge them on a regular basis. This starts to make engagement meaningful in my view.

Towards the end of the conference I also reflected on the customer experience of attending an event - from how important the first welcome is to how first impressions as a participant can colour the whole day. When we arrive at an event we may all be carrying all kinds of burden. We may have had a difficult journey, we may be stressed or we may have our minds in different places. Good events prepare for their customers and create a positive first experience. The first impression is often the last impression.

Book Review - Alternatives Beyond Psychiatry

I am finally getting round to writing a short review of this excellent book that was sent to me last year by a German based publisher called Peter Lehmann. Peter is a ex-service user and activist who has taken the publishing route as a way of inspiring change through stories and writing. He has also been very active in the European Network of (ex) Users and Survivors of Psychiatry (ENUSP).

The book is a series of chapters written by a mix of mental health authors. Some are professionals while others are service users. All share a fundamental perspective that the user voice is essential to the development and delivery of decent services. The book describes a series of different approaches that can support mental health service users towards recovery and challenge discrimination, unemployment and low income. Standout chapters include those by my friends at Bradford University on mental health, culture and ethnicity and a series of chapters on the power and benefits of self-help.

The writing is accessible with a good mix of personal stories and case studies combined with more academic references. It provides some inspirational examples and well as vivid descriptions of the barriers and difficulties people face as they claim their rights. What I particularly like is that the book addresses a full range of diversity issues including gender, culture, sexuality and disability without it feeling like an after thought or tokenism. Given the range of different authors - 61 in total - even if there are certain ones who you do not agree with, there are plenty of others that will resonante and also there are new authors and mental health activists to be introduced to for the first time in the pages. Highly recommended!

To buy a copy of the book you can contact Peter Lehmann publishers at www.peter-lehmann-publishing.com

Full reference: Stastny, Peter & Lehmann, Peter (2007) Alternatives Beyond Psychiatry. Peter Lehmann Publishing: Berlin / Eugene (OR) / Shrewsbury (UK)

What might PCT 2.0 look like?

With all the talk about Web 2.0 and the new functions available to users of the internet I started to wonder what a new generation of Primary Care Trusts (PCTs) might look like. Or maybe what might come next.

PCTs are the health organisations in the NHS that deliver primary health care services (doctors, dentists, opticians, nurses, health visitors etc) and they also commission services from other health care providers such as hospitals and specialist centres.

Whilst many local people are not that aware of what a PCT is and the role it plays, they are important behind the scenes players in the first points of contact people have with medical professionals in the community.

My view is that PCTs should be crucial conduits to local peoples’ engagement with all their local health services. They should work together to understand what local people need and want from their health system and then go out to make this a reality. PCTs should therefore have direct and deep relationships with their communities. 

They should be able to involve local people in all parts of the commissioning of services - including deciding on local need, procuring or purchasing services, monitoring how those services are being delivered and provided, and evaluating the outcomes of services which of course then feeds back into a new appreciation of local need.

PCTs should be organisations that do things with local people - not to them. Let us not forget that PCTs have big budgets of local peoples’ money and have to be accountable for this.

The question is, how can PCTs do this?

Traditionally PCTs have focused on delivering blocks of service and mass purchasing. They are part of the historical legacy of the NHS - coming with all the strengths and idiosyncrasies  that this unique and wonderful organisation has. And PCTs do a pretty good job for much of the time. 

I think there are at least six areas where PCT 2.0 could make a major shift in focus:

1. Building new and complex connections between patients, local people, health service planners and professionals - both in terms of vertical and horizontal relationships and in terms of more multi-layered non-hierarchical relationships. 

2. Finding new ways for people to come together to discuss health and be creative. PCTs unique position might give them the opportunity to facilitate and broker these new connections adding great new value to the local health economy. In doing so the PCT also becomes more valuable and useful to local people. One clear message from research into Web 2.0 is that people value the expertise of their peers and enjoying asking questions of people like themselves as well as to more traditional experts.

3. Increasing the availability and openness of information to the community about health services and choices - and making this information available in a variety of user friendly formats and in real time.

4. Capturing and sharing the experiences, views and local expertise of the community as both consumers of health services and as active partners in the commissioning of better services. This pool of knowledge and expertise could then be used for greater improvement and individuality of services

5. Offering new opportunities for voice, participation and involvement - especially from diverse groups such as young people, BME communities, disabled people and those who are terminally ill. Crossing the traditional boundaries of health and social care services and their respective silos to follow the real life journeys of people (whose lives are more rich and complex than our organisational structures can hope to recognise)

6. Looking at health services as a series of experiences that should please, satisfy and delight the user rather than as purely transactional relationships. 

PCT 2.0 will have to be very outcomes focused. Outcomes that include better accountability, transparency, participation and effectiveness. Of course this is probably also going to involve a major rethink of the power relationships between the users and providers of health care. This might be scary for organisations but who said change was easy. It might also mean that new skills are required.

Like the new internet, technology has a part to play in this shift. As data and information systems get better and less linear there will be opportunities to connect with different people in many different ways. It will also be possible to appreciate the resources that exist within the health sector and deploy these in different ways.

An added advantage of this direction could be that the greater empowerment of local people might reinforce the need for people to better self-manage their health and take control of their lifestyles. It is already becoming clear that whatever resources we allocate to health will not be enough for the increase in need and demand. But by supporting people to reclaim their health (recognising their own self-knowledge and expertise) it may be possible to use scarce resources more effectively.

It is fun to speculate and look to the future. In writing this article I am also painfully aware of how much jargon I have used - it just seems to flow out of my finger-tips as I type. One thing I like about Web 2.0 is that the conversation never ends - I am just waiting for other posters to challenge the jargon. Go for it. But also, in terms of PCT 2.0  the conversation should never end with our local communities. Engagement ceases to be a task and becomes a continuing process leading to growth and change. 

Perhaps in future PCT annual reports we should ask that they demonstrate the relationships they have built and the conversations they have sustained - if we could get a metric that gives a value to this on the balance sheet we might even begin to capture the value that this brings to local people!

The Last Motel....

I have been spoilt recently but the number of good hotels I have been lucky enough to stay in for my work. But I came down to earth with a bit of a bang today in Basildon.

I can only describe the 'motel' I stayed in as like something from the film Psycho. Very seedy and not very condusive to a relaxing nights sleep. The little prefabricated cubicles felt like prison cells. The big window faced onto the car park which was lit all night. The curtain did not cover the whole size of the window. The door did not feel locked even when it was closed.

I arrived late at night in the dark and managed to step right in a deep puddle just outside reception. The reception by the way is in a seperate 'shack' from the main motel. You are given a key and pointed to your cubicle and off you go outside again to find your room (and yes I managed to miss the puddle the second time around as I left).

But I survived the night and when the sun rose the next morning it did not look or feel quite so bad.

Infact, though the breakfast coffee I had was from a machine it was one of the best cups I have had in a while. 

The experience made me think - there is a big gap between services that are 'cheap and cheerful' (which I am usually happy with) and those that are 'cheap and nasty'. Which ones do we actually provide in our day jobs to our own customers, service users and the public?

Could LINks use Twitter?

I am down in Dorset working in Bournemouth and Poole this week running a series of workshops and planning sessions for LINks (Local Involvement Networks). Today I was based at AFC Bournemouth, the local football club.

LINks is about networks and mobilizing local voices. Twitter, the micro-blogging service, provides many possibilities for putting together real time virtual networks. Twitter uses SMS messaging on mobile phones to coordinate information sharing and action. 

Could LINks use Twitter - I think they could. It may be that members will need training and support to do this but I think the possibilities are very exciting.

Is the Google Foundation asking the right questions?

Google has recently made the committment to spend $2 billion on good causes through it's Foundation. Given the success of Google it is good to see them using some of their huge resources on social and economic development for poor people. 

Larry Brilliant, the new head of the Google Foundation, gave a very interesting interview about his aspirations for the Foundation and how they plan to spend the money. A strong focus will be on sub-saharan Africa which I welcome.

Being an innovative and successful technology company, it is little surprise that Google hope to deploy their expertise to try to solve some of the world's intractable problems - poverty, disease and environmental issues. They want to use their software tools and data analysis to predict and change the way development problems emerge. An example would be using software to understand and predict disease epidemics. Presumably once Google has the ability to predict these things it will be easier to intervene and prevent.

But is the Google Foundation asking the right questions? Does the world work in this way and can deeper analysis of data reveal new ways of making change happen?

Certainly it is appealing. But does it risk being too simplistic? The history of failed development approaches over the last 60 years has been littered with technocratic approaches to problems that just have not worked. Silver bullets offer the promise of a quick fix but they rarely work in the real world.

Robert Chamber's great 1997 book Putting the First Last provides an in-depth look at how technology has failed to deliver it's promises for poor people. Part of his analysis is that those who design and invest in technology are remote and removed from the poor and the real world and real lives that they lead.

There are many other factors than just technology to consider - power relations and dynamics; corruption and lack of transparency; trust; relationships; local knowledge and expertise. If technology is going to offer something then it needs to be used in a wider framework of grassroots development. 

I admire several things about the Google Foundation - their passion, their enthusiasm, their self-belief and their money! I just hope they ask the right questions (and ask the right people - those who live in the areas where they are trying to have an impact) before they spend.

The Best Public Toilet in the UK?

OK - I know this probably sounds a bit strange. But stay with me, I am going somewhere with this.

I was in Portsmouth on Friday providing some consultancy for a children's centre that delivers services for children with special needs.

When I arrive at Portsmouth Harbour railway station I needed to find a toilet. I managed to make my way across the fairly rundown station area and into the recently redeveloped Gunwharf Quay with it's iconic Spinnaker Tower.

In the shopping centre I found what I was looking for - a public toilet. However, this was not an average (which in the UK is usually fairly dire) connveniene. It was clean and warm. Rather than paper towls or fans to dry your hands it had those new Dyson hand dryers that work so fast you still think your hands are wet when they are actually bone dry.

It also had a basket of cotton towels. You were invited to use one and then place it in a wahing basket. It was really trusting people not to exploit this. Looking at the pile of clean towels it seemed to be working. Also, there were two options for handwash - both highly frangranced and expensive looking.

Having finished my 'abolutions' I was walking out of the toilets when my eye caught the paper cups and mouth wash supplied on the wall by the exit. Wow, mouth wash in a public lavatory!

Since leaving Portsmouth I have remebered this experience. It has stayed in my mind. I have told other people about it. I am writing about it now. And it simply was a public toilet - something that often does not register in our day-to-day life.

I think experiences are key. They are the things that make a difference to the service we deliver. People who use services want to feel valued, individual and respect. But many of our health and social care services do not offer memorable experiences. They may get the basics right but they are exactly that - a no frills bargain basic. If you listen to the consistent messages of service users across the spectrum of issues then a repeated complaint is the failure of services to be a good experience. Is it not then surprising people do not want to use them (getting labelled as 'hard to reach' into the bargain) and that stigma develops. Or that they resent the fact that services make them wait, wasting their time, at the doctors or the job centre or at social services office.

We need to raise the standard of the experience we offer when people use our services. We need to make them memorable so that people talk about them and recommend them to others. We need to learn from the private sector who are often far better at offering their customers an positive experience. They have a bottom-line that means their customers will take their business elsewhere if they are not satisfied. What a shame that our service users do not have so much choice to go somewhere different and better.

Some of the things that can turn an experience into something memorable are not that costly. Welcoming people, listening to them, designing your waiting areas with people in mind and supplying simple refreshments. Some of the things can be symbolic - giving the message that peoples' experience matters. For example, comfortable seats and decent light.

Surely if Portsmouth can get the experience right with their toilets then surely we can do better with our services.