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There’s nothing quite like being there


‘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.