Ten steps to writing the story of better patient outcomes.

Stories (or ‘narratives’) are a major part of our lives. Sometimes we tell them self-consciously – for example when we meet friends we haven’t seen for 4 or 5 years and tell them what has happened to us since we last met. We often think about what we’ll say before such meetings. Most will lie within the ones we have constructed about ourselves and our family.

We also construct stories about our work, and the organisations we work for construct theirs about themselves and our role in them.

I’ve been looking into the components of self-conscious stories for quite a while now, and I think there are ten steps to developing one for the NHS.

  1. Recognise the importance of staff and public motivation in creating a new model of care. This is a central point that defines why we need a narrative. The long-term plan will describe different things that the NHS must do. It will need its staff and the public to behave differently, and to do that they will need to be motivated to behave This motivation is crucial to change. Plans don’t make people change. In order to engage with the work and experience of health and social care in a very different way people will need strong motivation. Placing staff and the public in a new narrative of why and how they should change – to create a new model of care – is one of the ways in which people can be motivated to do it.
  2. Establish how staff and public understand the current model of care and how they talk about their roles in their current work. Creating a new model of care involves a lot of change, so it is important to empathise with the experiences of people who are going to be involved in that change. Before you develop any new story that involves people changing the way they work, you need to understand what their current work story is, and what their experience of care involves.At the moment most care experienced by the public is fragmented by different organisations and different specialisms. Staff work within their individual story (about their organisation and their specialism) but don’t have a story about the coordinated patient pathway. The excellent National Voices work on person-centred coordinated care demonstrated the problem that staff’s current story provides for patients.
  3. Recognise what problems staff and the public experience with the existing model of care and how those problems affect the existing narrative. On Monday I wrote about the NHS recognition that there needs to be a compelling case for change. However, leaders of current services are reluctant to say that there is anything really wrong with what we have been doing in the recent past. But it is vital that a new narrative contains a strong critique of the present because if it doesn’t – why are we doing something new?During most of the coming struggles for change the problems of the present will be obvious. At the moment the NHS and social care provide care that is fragmented by our own organisations. It is confusing, sub-optimal – and sometimes dangerous. If we don’t underline what we are currently doing wrong in our new narrative, why are we doing something new? Frontline staff often recognise what is wrong with the current narrative and these seeds of understanding may germinate a new narrative around a new model of care.
  4. When establishing a plan or vision for a new model of care consider how can it best be communicated to staff and the public through a new narrative of change. A good narrative needs to engage with the moral purpose of both staff and public and needs to move them from delivering and experiencing an existing model of care to where they need to be if a new model of care is to be created.The moral purpose that nearly all staff in the NHS and social care have is a considerable wellspring for change, but we rarely engage with it. This new narrative needs to do so self-consciously. The public are giving more of their money to the NHS – the NHS is there to care for the public and will do so in a better way because of this new money. Of course there are technical issues in this, but there are strong moral drivers too.
  5. Begin to develop the new narrative with staff and the public. A narrative created without that involvement will fail to engage. It will use the wrong words, the wrong phrases and will be ‘clunky’. (And given the smooth stories we now watch in this golden age of TV no one likes a clunky story). The next few months shouldn’t be spent trying to develop another 44 local NHS plans but with it developing the stories that will motivate change with staff and the public. People need to be fully involved in the development process. We must take the time to understand what they find successful, what they find problematic, and how they make sense of their current care model.
  6. Test the new narrative in a variety of different meetings to see how it works. Given the purpose of the narrative is to engage with various groups of people and to move them in the direction of a new model of care, it is important to have feedback on which elements of the narrative are working and which are not. If, for example, we are looking to increase cancer survival rates by encouraging the public to present their cancers to GPs earlier we need to know more precisely what will encourage them to do this. At the moment they probably don’t see ‘late presentation’ as a part of the causes of low survival rates. Over the last few years there have been some interesting attempts – for example the campaign to encourage people with a cough for longer than 3 weeks to go to see their GP – to encourage early presentation. What worked and what didn’t?
  7. Encourage staff, stakeholders and the public to talk about the narrative as a normal part of their explanation about what is happening. If we are to develop better outcomes for the public the new narrative needs to be a part of what people do every day. It’s no good if, in the middle of a consultation, a clinician picks up a piece of paper and reads something out which is abstracted from the consultation. It will be important to develop small parts of the narrative with a set of words and other descriptors that staff can use with different groups.
  8. Persist in consistently using the narrative as frequently as possible and on as many occasions as possible so it becomes a normal part of activity. It takes a long time using a narrative before even a small proportion of the staff and public become engaged. Leaders will feel self-conscious about using words over and over again, but it will take time for a new way of talking and thinking about things to become embedded. Different people will join in at different times. This is why it is important to reiterate the narrative with the same people on many different occasions and give them time to adopt it. When the narrative starts being used in different forums and situations in unexpected ways it will be a sign of success.
  9. Establish one person as the holder of the narrative whose task it is to understand how it works in different settings. The narrative may be used in different ways by people from different parts of the care system. This is why it is useful if in your local area one person is responsible for the narrative and its development. This will require talking to other people about how they use the story and how it could be developed, and then learning from and developing their ideas.
  10. Evaluate the impact of the narrative after six months. An evaluation is important because after six months the change process as a whole will need to be reviewed and an understanding of how the narrative has played a role will need to be evaluated.


For those that prefer moving pictures to words here’s a link I posted yesterday.

One Reply to “Ten steps to writing the story of better patient outcomes.”

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.