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Notes from the field of public involvement

Friday, 10 November 2006

What are users telling you? Further struggles with truth, perception and experience

Where is our Consultant Philosopher when we need him?

This entry picks up on Andrew's last blog which alerted us to the risks associated with a gulf between perception with reality. With blog topics like these, the Partnerships really needs the wisdom of our philosophy consultant Harry Adamson. He however has sloped off for a year at Harvard's Graduate School where he assures us, his exploration of the higher realms and topics of philosophical thought means he is not available to answer these elementary and mundane queries. (This message reaches us from the taverns of Cambridge, Mass). So we will have to struggle on by ourselves, unpick some of the issues around the data and see how we can resolve some of the apparent contradictions and make the data trustworthy and actionable.

Contradictory Findings
Andrew, in his last blog posting on the State of Healthcare 2006, pointed to the fact that while most people said that their own experience with the NHS was positive but that in their view, the NHS had got a little or much worse over the past 10 years. What does this mean and can we reconcile these views?

In one sense, the answer to the problem of a difference between perception and another 'more true' version of reality is easy in a customer service context. Address the perception and treat it as the relevant version of the truth and if you can change that, it will become the reality. But that advice is difficulty to put into practice for a number of reasons.

A Definition of Perception
The one I want to explore today is that perception is much a broader measure than experience. It is therefore difficult to identify what buttons to press when change is needed. Our take on this is that while experience is at the heart of user opinion, perception is the result of the way that people augment their individual direct experience. They reach a final judgement that takes in the experiences of others and information from other sources. The two states are linked and are interdependent but different. In building a complete model of customer satisfaction, we must find a way of linking and reconciling them.

Building Satisfaction at All Levels of the Customer Relationship

Moving out from the direct experience
The questions we ask start with the experience, move to past personal knowledge, then what the user has learnt from other sources and end with a general overview which we call perception.

The first question deals with the specific and the personal and then the questions broaden to take in indirect sources of user learning and opinion. People can answer the subsequent questions without having used the service at all. These 'no-experience' verdicts are formulated on the basis of the experience of others. Theses judgements we can call 'perception-based' and when aggregated in a public arena, we can re-label them as constituting 'reputation'.

We argue that it is the reputation - defined as individual perceptions taken into and embedded in the collective mind - of a service that is often used as a basis for action by regulators or legislators far distant from the individual experience of care. We are left with the paradox then that those with the greatest power to influence NHS service provision - its standards, its quality - are those furthest separated from the experience of either delivering or receiving care.

OK but how can we reduce this gap of understanding and work the data to provide a better basis for decision-making by those distant deciders? Can we suggest a basis for understanding our data better and seeing our way more clearly to improvement action?

User Information Sources
In considering sources of information, the customer takes information from a variety of sources. One of the most important - because it is most trusted is the opinion of friends and family - is word of mouth. In the context of customer service, another important source is their experience of service in other markets. Their experience and hence expectation of service grows in proportion to their exposure to lots of service and in particular is shaped we would argue by the extremes - the best and the worst. Their expectations rise very fast - service managers have to come to terms with the phenomenon of how quickly new and successful service initiatives are seen by customers as the norm and they immediately want more. So ask about who they listen to and trust and also their other service experiences to discover which service providers they are benchmarking against.

Acquiring Market Skills
What we might call the users' 'market skills' rise in proportion to the number of times they enter the market and buy something. Most have very clear expectations of what they buy weekly in the supermarket but are very vague about more complex products and services that they both buy and consume less often - think endowment mortgages. So ask about what they have bought recently and how often do they shop for that sort of thing eg food or a holiday.

The Reputation Time Lag
This question of frequency of use also has a great bearing on the speed with which the attitudes associated with the fact of the (good) experience percolate into the collective perception. It was much debated in the 80's how much Rover's recovery was impeded by the fact that it had built such lousy cars in the 70's. The memory of the Allegro still dominated the experience of the newer and much better Rovers of the 80s. That time lag in reputation repair must have contributed to driving Rover down the drain.

Any analysis would then be segmented by user - based on the way and the frequency they used the health service and related to their broader purchasing experiences/ habits.

Moving to Action
So in conclusion we would understand better what you are hearing about and the extent to which the views reflect a direct experience or an indirect one. Direct experience can be applied in service improvement programme in a ward or a GP practice or an airline cabin.

The indirectly acquired views - which we are calling perception or reputation - are best addressed by identifying who holds them and finding a way to talk to them and expose them to the most recent direct experience data. They would still have views on the organisation but at least those views would be based to a greater extent on current information gleaned from actual users.

Reconciling Contradiction
However in the NHS context, things can get even more complicated and we have this phenomenon that Andrew identified of people apparently holding two contradictory views at once - yes the NHS is OK but yes I am still worried about it.

There may be a clue in what we heard when we did a focus group with people with disabilities who were highly experienced users of health and social care services. They still had their problems but were ready to acknowledge improvement - attitudes had changed for the better and the increase in resources had helped a great deal. Here the collective judgement was in line with the individual experience built sadly over a life time for many of those we talked to. NHS good.

But they were still worried.

Why? Perhaps because the NHS and other organisations providing their care are not environments where service development appears to be connected to the individual experience. High quality services which are valued and used may disappear - not because users have turned their backs on it but because of an administrative or fiscal fiat from on high.

This translates as users worrying about the 'service instability' of the NHS and of social services. It is another irony of the NHS - an enormous Jumbo Jet of an organisation - that its service environment is so fragile and volatile and seen by its users as being completely outside their control. They get excellent service in one place and rotten service in another. One day the service is excellent and then when they come back in a few months, it has disappeared - reorganised, withdrawn, disappeared.

So we can see that the experience of being an active consumer informs judgements about the past or the present. But that experience also tells them that the future is more unknown and risky. They ask themselves "If massive amounts of money have been put in, how long can that last?" or "Will we once again see user expectations built up in a period of relative feast be disappointed as the famine returns?"

This insecurity has to be one reason for people fight so hard for old institutions and the old ways of doing things. They are reacting against a service that is or will be vital to them but is seen as being unpredictable and unresponsive to individual and local need because its masters live a long way away from the services as delivered. Those decision-makers rely for their decisions on reputation - a perception which is not based on a reality users would recognise.

And in this situation, they cannot buy a Toyota instead.

Read more about M-A-C's thoughts and approaches on collecting and understanding consumer and user data, and our article Emotions in Decision Making where we put our principles and experience to work and add value to research by understanding how to use data and also how to get data that is useable and prompts action. We like to field our surveys in partnership with Surveylab.

Colin Adamson | (Problem occured connecting to database: The server requested authentication method unknown to the client