wait longer than eight weeks for initial assess-

ment was the first move in harmonising a range

of various caseload management practices across
our district and was therefore an extra benefit of
our first users views activity.
At this early point in our users views evolution, we
decided it was important users did not meet with
their therapists. We thought that might inhibit
honesty, and be difficult for the therapist. On a pos-
itive note, we did feed back to those who attended,
our team, fundholders and commissioners.
In the next two years we continued with focus
groups, planning to ensure we covered all geo-
graphical areas of our Trust and adult users as
well as carers of child users. The senior manage-
ment team shared out the work
so, for example, a paediatric
team leader would run a group
for people who had had a stroke.
We continued to report back and
started to work out what
changes we could make.
In 1996 Julia Ritchie and I wrote a
document for our Trust called
Informing and Listening. This
looked at the literature around
users views and current practices.
We read and visited, and became
even more convinced that this was
a valuable addition to our work. We became less
anxious about the meetings, and better at encour-
aging people to tell us their story. We learned that
people could hold painful memories of diagnosis
and the realisation of the extent of difficulties
described by us. These were often not anyones
fault - they just were.
Other times, small changes could make a big dif-
ference. For example, feedback from therapists to
parents about group therapy performance is hard
to take if it is felt to be always negative about
behaviour and is delivered in a busy waiting room.
Similarly, it was great that children with disabilities
could come to therapy at a local clinic instead of
only at the Child Development Centre - but not if
the therapist forgets that your child cant walk
into the room alone and she is left in the waiting
room without help. In both of these instances, par-
ents had concealed their hurt at the time and had
only shared it when asked about their experiences
in what felt like a safe setting for them.
Benefit of hindsight
After three years of our rolling programme of
focus groups, we took stock of what we were
doing. On the plus side we had maintained activity
management
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2003 8
first remember being asked to think about
users views in the late 80s, when I was told
to produce a questionnaire, evaluate it, and
write a report about it. Thankfully, I cant
remember many details of the paperwork I
inflicted on the carers I worked with. If I
could remember more, I am sure I would recall a
number of embarrassing errors.
It would have been from my perspective. I knew
what people needed from my service, didnt I? It
was paper based and therefore not easy to use for
people who are not confident readers and writ-
ers. I am pretty sure I didnt feed back to those
who were kind enough to respond - just to my
boss. Even worse, I cannot remember making any
changes to my practice afterwards.
Luckily, I was given a second chance
when I moved into management
myself. A colleague was taking her
masters in Health Psychology and she
suggested we start to ask parents of
children using community clinics what
they wanted. We were dealing with
huge waiting lists and at the start of
GP fundholding. It didnt feel right to
leave users out of the equation. (Can
anyone else recall those discussions
about who our customers were and
the linguistic gymnastics that took
place to put GPs and commissioners above users?)
So, in 1994, Julia Ritchie and I ran our first focus
group. We invited 60 randomly selected past and
present users of a clinic in Chatham to an afternoon
meeting. Ten people came, and others rang or
wrote with their views. I saw my first example of a
phenomenon since seen many times - people who
have had cause to complain to our service being the
most giving and energetic in sharing their ideas.
High on excitement
We prepared for the meeting by agreeing that we
principally wanted to know users views on waiting
times. Should children be seen quickly and learn
if there is a problem, but then wait for input? Or,
was it better to wait longer but get intervention
straight after assessment? Families were clear that
they wanted to be seen as soon as possible and to
use waiting for therapy time to put therapy sug-
gestions into practice. In discussion, it was felt that
eight weeks was a reasonable maximum initial
wait, and Julia Ritchie and I used this in negotia-
tions with commissioners. It was not always a
comfortable meeting, but it was lively and we left
it rather high on the excitement.
Shifting our clinic work so that children did not
l
I saw my first
example of a
phenomenon since
seen many times -
people who have
had cause to
complain to our
service being the
most giving and
energetic in
sharing their ideas.
Medway speech and
language therapists
have been seeking
users views for over 10
years and, more
importantly, changing
services as a result.
From cringe to credit,
Val Levens shares the
wealth of experience
they have amassed.
you want to
deveop condence n workng
wth users
encourage reecton on
therapy by those nvoved n t
harness the energy and deas
o admnstrators and
companants
Read ths
I know what people
need from my service -
and grown our skills and confidence. However,
the importance we had placed on users not meet-
ing with their therapist had had paternalistic
effects we were not happy with. We had kept the
work within the senior management team and so
prevented others developing the skills we were so
proud of. We had missed an opportunity to
encourage reflection on the therapy experience
between those actually involved in it. With the
benefit of hindsight this is so obvious!
How could we open up this work throughout
the department? Also, having decided that face
to face was a better format than paper based
methods, were we relying on it too exclusively?
We came up with the idea of a Users Views group,
which would involve a representative from each
therapy team in our department (adults, paediatrics
and special needs). This group had a coordinator
and met regularly throughout the year. The team
representative model encouraged whole team dis-
cussion about areas we could explore and was the
prompt we needed to widen our range of action.
Having successfully won a Charter Mark award
for our department, we learned from that process
too. We were not especially good at reporting on
some of the positive things we did - so we started
to produce an annual Users Views report. This
enabled us to share our learning with others in
our Trust, and allowed us to find out more about
each others projects.
Thinking we could make more use of our
monthly department newsletter to keep Users
Views a live issue, we began producing a termly
Users News attachment that contained snippets
of news, thanks to those who were already par-
ticipating and encouragement to everyone to
think about how they were - or could be -
involved. This may be one of the reasons that the
last few years have seen plenty of volunteering
behaviour. Looking at our review of work in 2002
(figure 1), there are a number of projects that
have been conceived and completed by people in
our teams without any prompting. Written up
projects arrive with post-its saying, I was doing
this anyway and realised halfway through it was a
Users Views project. People on the Users Views
group now are not surprised by calls that start - I
had an idea ......., or What about trying....?
A member of our administration team said she
would like to be on the group. She contributed
generously and enthusiastically, especially in
prompting discussions about the therapist/therapy
focus of so much of our thinking. For most users,
their first contacts with us are through administra-
tion services, either in person or by telephone or
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2003 ,
management
letter. How much thought were we putting into
these? How could we reduce missed appointments
by manipulating the timing of our appointments
(eight weeks notice or two? - what we actually
found is that, if a client or their carer works, more
notice is helpful but, otherwise, less is best).
One of the strategies we have used is the per-
ception scorecard. This is a page of 10 boxes, with
one at the top. It can be used in a
number of ways; one of the most
useful is to fill in the boxes with an
individual or group, firstly listing 10
things they think are important
about the service. These are then
ranked in perceived order of impor-
tance. Next, the group gives marks
for how well they think we are
managing that issue. It is even more
interesting if those delivering the
service do the same, logging their perspectives.
Process most valuable
Comparison, sharing and exploring perspectives
prompts lively debate. Actions can be agreed on -
which areas to target and how. However, in all of
this it is the process that is the most valuable. We
need to ensure we do not rush for outcomes at
the risk of missing out the gold that is revealed in
getting to them.
It is usual for therapy teams to have different pri-
orities from users. In a way it is both inevitable and
right - we train to identify and manage communi-
cation problems. We are drilled in efficiency and
evidence. That is valuable because no one wants
us to waste money or time. However, we still need
to know what makes contact with us as positive an
experience as it could be and, as the comments in
figure 2 show, our team really sees the benefit.
We think we have come a long way - long
enough to cringe at some of our ear-
lier attempts at least! We are more
relaxed about the work now, and do it
more readily, often without even real-
ising we have. We are not complacent,
though. We are all too aware that
gathering the views of those with
severe communication problems is a
challenge. We want to do it in ways
that are meaningful to the user and
which, in themselves, contribute to the
therapeutic intervention.
Suggestions for bringing users in and the differ-
ent techniques for gathering their views are in fig-
ures 3 and 4. We will continue our rolling pro-
gramme, always looking for new / better / differ-
ent ideas. If you have some you would like to
share, call us - we would like to hear from you.
Val Levens is a speech and language therapy manager
for Medway Primary Care Trust, tel. 01634 813738. She
thanks Julia Ritchie for her inspiration, and writes this
on behalf of Terri Horton, Vicky Kiely, Siobhan Letford,
Susan Tyrrell, Louisa Waters and Janice ORegan.
We are more
relaxed about
the work now,
and do it more
readily, often
without even
realising we
have.
+. Get started! (You w earn whatever you do.)
. Nake t peope to peope contact. (You can try paper systems ater.)
. lsten more than you tak (and sten to the avour as we as to the content.)
(. Vaue process more than outcomes. (You w earn more n the journey than on arrva.)
. Keep t smpe. (Ouaty not quantty. Ask or a good thng about contact wth you, and
or a bad thng. You may be surprsed.)
Users vews: steps to better practce
dont I?
Figure 1 Projects undertaken in 2002
- Contact with carers of adult patients (what did they think about it?)
- Sensory interaction project (staff feelings about how we planned and delivered the work)
- Parents/carers views on group therapy (community clinic)
- Reflections on a drop in clinic (community clinic)
- Autism group (childrens views of the group)
- Training feedback (what I did this week parent/carer thoughts on introduction of
symbol feedback in a nursery)
- Leaving the unit (children with language disorder thinking about their time with us).
Figure 2 Team views
Its what really matters in planning how we improve things.
I enjoy the opportunity to really ask people what they think.
It seems daunting at first but soon becomes part of everyday working.
Things that other teams do can be really useful to see, because it can often be adapted to
my work too.
Figure 3 How to meet people you can use
- Talk with people in the waiting room.
- Visit a support group, where people
may feel more confident.
- Invite a few people for coffee (and
cr` eche).
- Arrange to meet someone who has
complained about the service.
Figure 4 Techniques to gather users views
- Open discussion
- Guided/interview
- Structured interview
- Perception score cards
- Drawing how you felt/feel
- Using composite pictures to express views
- Feedback slips on reports
- Suggestions box
- Telephone feedback
Whatever you do, include an anything else? section.