There’s nothing quite like being there

This content relates to the following topics:

‘Civil servants will be swapping the corridors of Whitehall for the NHS front line’, the Department of Health announced last week. As part of the efforts to foster a more patient-centred culture in the Department following criticism in the Francis Inquiry report, all senior civil servants will be expected to spend the equivalent of four weeks a year with staff and patients in health and social care organisations. Other policy staff will also be expected to engage in the programme, though the time they will commit to that has not yet been confirmed.

This initiative presents an excellent opportunity for the Department’s work to be better grounded in the complex and messy realities of health and social care provision – and to better serve patients and their families. My own research on how civil servants in the Department learn about health policy issues found a tendency to rely on a limited number of contacts-of-contacts for oral briefings, and to create simplified diagrams or categorisation systems in order to turn highly complex issues and systems into simpler phenomena, which are easier to conceptualise, and seem capable of being directed by policy. While these are essential tools for civil servants, they must be balanced with a real sense of the complexity of life in A&E, an adult social services department and the GP’s waiting room.

Think how different the task of restructuring the health service would be after accompanying a nurse who is trying to organise discharge care for a frail elderly patient, compared with sitting at a computer screen in a Whitehall office, moving boxes around on an organogram.

In fact, when the civil servants in my study did have experiences of frontline care, either through organised professional visits, or in their personal lives, these had a profound effect on their understanding of issues. There is something about the authenticity of first-hand experience that brings issues to life, makes them feel real, and generates a sense of understanding you can’t get from reading articles and data. Anthropologists and ethnographers have been using and developing these immersive, holistic techniques to study the social world for more than a century.

But while this kind of engagement can generate highly valuable insights, it must be accompanied by critical thinking and discussion that puts the learning and understanding into context. Psychological experiments have found that we tend to overestimate the extent to which we know about or understand an issue if we have had direct personal experience of it. Nobel prize-winning psychologist Daniel Kahneman refers to this as the ‘what you see is all there is’ effect. We cannot expect civil servants to engage in full-blown academic studies to test the robustness of what they learn, but they should be provided with a forum, and support and challenge, to examine what they have understood from their experiences, using them as a prompt for further inquiry rather than a straightforward prescription for new policy.

There are other practicalities to be considered. For example, is the programme prioritising the right people? My experience of the Department was that very senior civil servants already use existing contacts to visit organisations, and, by virtue of usually being older than junior colleagues, often had more personal contact with services through their own care needs or those of relatives. Mid-ranking civil servants, who are engaged in the critical work of fleshing out policy content, generally had fewer personal experiences to draw on, and much less time and fewer resources to make frontline visits. Thought will also need to be put into how such visits can avoid the formality and performance of royal walkabouts, creating a nuisance for staff and little genuine insight for the civil servants.

The Department has committed a considerable amount of staff resource to this initiative, which has the potential to inject real insight from staff and patients’ experiences of care into national policy development. All the more reason to get it right.

Related content



Director of Strategy and Innovation,
BT Global Health
Comment date
28 May 2013
Good idea. There are three types of wisdom:
a) Received wisdom
b) Contemplated wisdom
c) Experiential wisdom
The third is the highest form. It is important that people framing policy get the benefit of experiential wisdom. That would help limit the unsatisfactory consequences of some of these changes.

Dr Darren Kilroy

Director of Network Leadership and Development, Unscheduled Care,
Stockport NHS Foundation Trust, Bolton CCG
Comment date
28 May 2013
Always good to approach sensible policy-making by broadening the experiences of those within an organisation charged with running it. But the fundamental issue is, arguably, re-appraising who should be charged with setting and enacting policy, rather than orchestrating work-experience programmes. Perhaps if there were a smaller, more clinically-connected policy team then progress would be more efficient. It will be hard to tease out any rea;-terms improvements in patient care quality from this initiative.

david oliver

Consultant Physician,
Royal Berkshire NHS foundation trust
Comment date
28 May 2013
When i was still the NCD for older people, i regular hosted senior civil servants for a day, spending time on call with me, going on to ward rounds, then meeting staff involved in patient discharge and then out to community services. All of them embraced this experience enthusiastically and all made it clear they had gained a great deal from it and had a better understanding of how policy decisions affected frontline service delivery. I have a great deal of admiration and respect for the civil servants i worked with and the pressures they work under and with the exception of the odd one who is clearly angling for a job in the consultantcy/private health provider/telecare/telehealth sector on the back of their government role I can't fault their dedication and committment. But if you spend your time dealing with think tanks/commentariat/policy world. most of whom have no real current grounding in frontline services, it can give you a distorted view. Take for instance the nonsensical assertions that on call doctors are admitting patients to create tariff income for the trust (even though most have little understanding of the tariff and are desperate for beds). If readers google "martin mcshane BMJ blogs smelling the coffee" they can read about a recent experience of a senior government official getting a taste of the "coalface" and his reflections on it

David Oliver

Add your comment