At the end of last year Involve was commissioned by Newham Clinical Commissioning Group (NCCG) to review its Patient and Public Engagement (PPE) work. It was a task that involved interviewing and then bringing together representatives from amongst NCCG staff and board members, health providers, the council, patients and the local voluntary and community sector. It looked both backwards at what had been done so far, and forwards to creating NCCG’s new PPE strategy.

It was in doing the latter task that an aspiration for transformational engagement took centre stage. It was clear that participants wanted it, but what did it mean? This is, of course, an excellent question. For me, one part of the answer is about the subject to be transformed, the other about the level of decision-making involved.

In Newham, participants tended to answer the question with a focus on outcomes. Engagement was transformational if it resulted in a significant shift in the health and wellbeing of the local population. I think this makes a lot of sense, but there are other possible subjects too. For example, engagement could be seen as transformational if it becomes embedded throughout an organisation, changing its culture and how it works. It could also be transformational from the patients’ point of view in terms of their experience and the skills, knowledge and change in mindset it could engender.

In some ways these subjects are not mutually exclusive. Outcome transformation may be impossible without a significant change in organisational culture and practice. Organisational transformation may be meaningless unless it leads to a step-change in results. Both of these forms of transformation are unlikely if engagement is poor quality. And high quality engagement entails a strong focus on patient experience (although this is not the same as a focus on transformation in this area). What’s important is not which of these forms of transformation are ‘better’, but an awareness that they exist and clarity about what a particular process is trying to achieve.

In a similar way to the subject or aim of any transformation, there is also a question about the level of decision-making to which transformation applies. It is my starting proposition that there are three levels of transformation here:

  1. Transforming a single area of work or cross-organisational function: For the example of a CCG with which I started, this level of transformation could include PPE around the design or re-design of a service. It might also entail engagement on a cross-organisational issue, such as how data is used and shared internally, or the development of a new PPE strategy.
  1. Transforming an organisation’s agenda: One limitation of the above level of transformation is that engagement only happens around the areas and issues that an organisation has decided are a priority. This misses an opportunity to understand where the key problems are from an external perspective and to adjust strategies and agendas accordingly. Participants in Newham came up with a wide range of suggestions for how this could work for a CCG, from an annual civil society survey, to permanent stakeholder groups.
  1. Issue- or place- based transformation: Finally, the issues with which an organisation deals are rarely only affected by its own work. The work of a CCG is clearly a case in point: not only are there multiple organisations with direct health responsibilities in any given area, but housing, air quality, social isolation and a plethora of other factors are influential too. Transformational engagement could therefore be about joint engagement projects which see a range of organisations working together to engage the public and other stakeholders in exploring and developing solutions around an issue. This could involve a smaller (e.g. everyone involved in prevention and care around diabetes, including patients) or larger (e.g. how do we improve health and wellbeing in this area) question. The role of engagement in initiatives around place-based health are an example of this transformation level.

As with the question about subjects of transformation, none of these three transformation levels is inherently better than any other. All have the potential to achieve significant results, not least in the lives of people served by the organisation.

But transformational engagement is also clearly not a term to be bandied around. If its possibilities are so varied and vast, then pinning down what is meant by it seems like an essential first step. After all, you can’t achieve something if you don’t know what it is. Whilst this clarity and consensus around focus may not be easy to achieve, it is possible. To return to where I started this post, the diverse range of stakeholders in Newham cracked their definition in a single workshop.


Image credit (for the image linked to this post on the main Involve blog page): Shannon Hauser, flickr creative commons.