If we want new practice, we need new narratives for change | Professor Paul Corrigan

Paul Corrigan

The narrative for change must go beyond a vision of different ways of working, writes health policy expert Professor Paul Corrigan. 

There is a persistent myth in the NHS that policy drives change. The myth goes thus: clever people think clever things and write them down, and when they gain the authority of a large organisation, those clever ideas become policy. 

Those of us who write policy believe the lucidity of the argument (plus the power of the organisation that backs the ideas) drives change. For policymakers, that’s a great idea – it gives us the idea that we make the world. The truth is, it doesn’t work that way. 

What changes the world is changes in practice. While many people engaged in day-to-day practice are interested in policy, if policy doesn’t engage them in such a way as to change their practice, very little happens.   

What gives leaders and staff the drive to create new models of care are two big drivers for change. First, they have to really believe their day-to-day practice in the old model of care doesn’t work as well as it might for the public. Second, they believe that if they were to work differently, they could do something much better for the public. If people that lead and carry out practice don’t believe that, then nothing that policy tells them to do really changes practice.

Leaders that want to bring about new models of care have to start by strongly believing it’s the right thing to do. Given how tough the process of change is, if leaders don’t really believe that they want to change day-to-day practice, then it’s not going to happen. 

Most radical change recognises that this initial moral drive is the necessary beginning of change. Then what is needed is a really good narrative that tells us how the different work we do will fit into that story of change.

Contrary to what policymakers believe, most people don’t work to policy – they work within a narrative. I come to work each day within a story of my life at work. I may, for example, be a diabetologist who has trained and studied for 12 years to be one the best in the country. I use my knowledge and training to treat diabetes and improve the lives of people who have diabetes.

The fact that in 2017 there are more people with diabetes means that I am very busy and we need more people with my skills and my story to continue to improve. The fact that 80 per cent of the people I treat have another long-term condition is a set of stories that belong to other people. 

If we are going to persuade that diabetologist that their best work would be as part of a multidisciplinary team which includes not only other specialists, but also domiciliary care workers, GPs and a voluntary sector walking group, there needs to be a new story that they can place their passion for their work within.

That’s why if we want new practice, we need new narratives for change. And the stories need to go beyond a vision of a different way of working. People need to be able to see themselves, their diary and their work in that different story.

Around the country, many leaders get the necessity for a narrative at the start of that process, but the important part of change is to see it as important throughout the change process. 

One of the main experiences of the leaders of multispecialty community providers that I worked with was the necessity to ensure the narrative begins and ends with patients. 

Across the country, the development of change in different local areas has often been developed around a typified member of the public – Mary, or Bert, or Naresh. The narrative starts with the fragmented services these individuals currently receive. The number of times every month they have to tell their story to different organisations, operating different access processes which they have to navigate. The narrative could then end with a different service which is coordinated around their life, recognises the assets they have to work within and how those coordinated services reflect their needs.

In between the narrative will contain a lot about the processes of change that all the organisations have to go through. The new team meetings, the new financial flows, the training, new job descriptions all will need to be a part of the story. And so often when you are 90 minutes into a meeting about the new financial flows necessary for the new model of care it’s very easy to forget why all of this matters. 

That’s where the narrative comes in, where someone needs to have the nerve to say in the middle of all of the stuff of change, “How will this make it better for Mary, Bert or Naresh?” How can that moral driver for change act as the necessary renewable energy for change?

That’s why the story matters so much to keep driving the change even when we are all a bit tired.

Professor Paul Corrigan is working with NHS England to help develop new models of care, with a particular focus on multispecialty community providers. He is a non-executive director at the Care Quality Commission and adjunct professor of public health at the Chinese University of Hong Kong and of health policy at Imperial College London. Follow him on Twitter @Paul_Corrigan

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