The experience of policymaking in healthcare : the interaction of policy formulation and frontline staff practice

My research focuses on the experience of policy development and implementation. It draws on my involvement in a government policy taskforce, the development of an organisation’s strategy to the taskforce’s recommendations and the commissioning of frontline services. The research material is my personal experience contained in a number of narrative accounts of important happenings. These are then used as a basis to engage with literature and conversation with practitioners, academics and fellow researchers. It is from this iterative process that the argument develops. The approach is therefore qualitative and reflexive in nature. I have argued against the traditional separation between the content of research and methodology. This is on the basis that human experience does not distinguish between the two as we make sense of new emerging situations. The research has been heavily influenced by analogies drawn from complexity sciences as a way of increasing our understanding of ongoing human interaction, namely complex responsive processes of relating (Stacey et al, 2000). By paying careful attention to the experience of policy development and implementation over an extended period of time I am illuminating that the development of policy can often be seen in literature and in the techniques people use as an activity that is isolated from the work of frontline staff. For example, a policy group is formed, policy or a strategy is drafted and the work is then seen to be done. This can be demonstrated by paying attention to the modus operandi of how policy and strategy groups work and how performance criteria are established. When it comes to frontline practice, policy is often silent to the multitude of unfolding interconnected possibilities that present themselves to practitioners as they seek to go about their activities. The way that policy is often presented implies that there is linearity from policy to implementation. Drawing on Elias’s notion of Involvement and Detachment (1987) I am highlighting a paradoxical relationship between policy and implementation. In introducing the notion of paradox, there is a “vitality” that is required to prevent a collapse to one of the two ends of a continuum; for example a conscious or unconscious rejection of policy in favour of embracing frontline practice, or an over reliance on policy to blindly drive through organisational change. In spending three years looking at the policy and implementation I argue that it is more helpful to consider policy and implementation as a “flow”, rather than a series of discrete activities that are seen to be completed before moving to the next policy area. In looking at policy as something that occurs over a span of time (as opposed to an isolated bounded activity) there is an opportunity to prevent the collapse of the paradox outlined above. By accepting the concept of paradox and considering policy from a temporal perspective, rather than one that is a spatially bound system, the issue of policymaking practice can be considered. There are books and management experts that recommend that managers should “walk the walk”, and get closer to frontline activity. My research has sought to add clarity here, arguing for an experiential and temporal form of reflexivity of practice (as opposed to reflective practice). In this context working and being present with frontline practitioners, paying very careful attention to the experience of the unfolding contingent nature of activity influences the practice of policy making. This is a different experience from simply being present, and being seen to be present. It would be ironic for my research to be converted into a policy document with key elements extracted and condensed into bullet points to be applied like a rule. Instead my research is best kept alive in evoking stories and reminiscences between people as they make sense of their experience of policymaking and implementation together.