We were only sixteen (AfterSam Cooke)

Note: the views in this article are personal, theydo not represent the view of the organization theauthor works for, nor the practice developmentunits (PDUs) he has been involved with.

The central tenet of the practice develop-ment unit concept is the notion of ‘develop-ment’; taking that twinkle of an idea and turn-ing it into a star. The metaphor of an acorn toan oak is the image used by the Centre forDevelopment of Healthcare Policy andPractice itself. This is a powerful metaphor,one of roots, moisture, growth, strength, syn-thesis, light, shade, power and life. There areother metaphors for development, and the onethe author has chosen as a vehicle for thisopinion is the development of embryo intobaby, baby into child, child to adolescent, ado-lescent to adult.

I have been involved in three PDUs, beingthere at the point of conception, and sharingin the gestation and birth. As an accrediteeand accreditor I have experienced that greatshout of triumph at the end of a laboured butsuccessful accreditation visit. I have shared thehugs, tears, phone calls, cake and champagne.

But those of us who are parents know thatthe joy of birth is followed by a desert of sleep-less nights, messy nappies, the first day atschool, the first boy or girl friend, and thatgreatest of change agents – adolescence. Andalong with adolescence comes reaccredidation.The unit is now more mature, able to stand onits own two feet, and take the PDU upbringingand apply that schooling to life. But those of usyoung enough to remember, can reflect onthose raging hormones, the embarrassments,the clumsiness, the yearnings, and that greatKevin and Perry grunt of ‘It’s not fair’

Carr-Gregg and Shale (2003) outline threestages of adolescence, characterized by threekey questions: Am I normal? Who am I? Whatis my place in the world? At times it is no funbeing an adolescent. At times it is no fun beingan adolescent unit either. Mum and dad wereinseparable when they conceived the PDU

dream; they were a team with one thing ontheir mind, but as the years pass the teamchanges. Adolescent units will have had toaccommodate a number of team changes.People come and go, and each new memberneeds to be courted and enthused by the PDUethos. The 15 steps to heaven. Innovation?Evidence-based practice? Research? I’ve gotwork to do. What metaphor shall we use formanagement speak? The many headed Hydracomes to mind. ‘PDU? Splendid, well done,credit to us’ says one head, while the othereight shout about local delivery plans, servicelevel agreements, national service frameworks,targets, overspends, ‘must do’s, ‘might do’s,‘ought to do’s, ‘just do it’s!

The question that stands out starkly, bothfor the Centre for Development of HealthcarePolicy and Practice, and for local management,is how best to support these units at this stageof their development? How can we help themframe a relevant answer to the three questions?Furthermore they need an answer which stillcaptures that desire to make things better forpatients. It is that passion and desire whichwill make a lasting change, that saw themthrough the birth, and will take them throughadolescence into adulthood.

Superficially the answers are straightfor-ward.

Am I normal? The short answer is no, ifnormal is defined as not being special, notbeing different, not being exciting. PDUs are,by definition, special, as they have gonethrough a development process and journeythat sets them apart. They have been assessedagainst objective external criteria, and have acertificate to prove that they are different fromthe norm. But – star status brings problems ofcelebratory status, envy, public scrutiny andthe energy demands of continuing to twinkleand shine.

Who am I? Easy: ‘The unit has a clear anddefined client group focus’ (University ofLeeds, 2003). The units know who they are andwhere their boundaries lie. But, no unit is anisland, and the pressures from within and with-out ebb and flow, with an increased emphasis

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on results, finance, targets and performancemanagement that can sap self-confidence anddamage a sense of certainty and self-worth.

What is my place in the world? Criterion14 (University of Leeds, 2003) says it all: ‘Theunit acts as an agent of change within theorganization, the region and nationally, publi-cizing its success to promote the value of bestpractice.’ But, change management is morecomplex than three dimensional chess. Thereis no safe, unmoving point from which tolaunch attack, defence or an initiative. It fol-lows that building confident answers to thefirst two questions is a good foundation to tack-le this third question. We should join withthem in the words of the Toyah Wilcox song,‘Be loud, be proud, be heard’ .

A key function of the Centre forDevelopment of Healthcare Policy andPractice is to challenge. Evidence-based prac-tice de facto challenges units to research,review and define a solid foundation for whatthey do. The politics of challenge is based onthe weaker challenging the stronger (Ryan,2000) and is born of an intuitive, grass rootsknowledge of what real life is like. Perhaps it isnow time for the adolescent units to challengethe Centre for Development of HealthcarePolicy to reflect on the nature and structure ofthe support that they provide for them, andhow further growth and development can be ofbenefit to both parties. In particular, theCentre could:

● Provide support in continuing change man-agement. The units I know well have beenthrough substantial changes, and havetaken on more or different responsibilities.They need to be able to continue with theirearlier vitality and energy

● Develop modules in influencing skills.One of the PDU objectives is to influencepolicy at a national level, but gawky ado-lescents need confidence in their ability tobe heard on a national stage

● Help keep the faith and the vision alive.The biblical image of the young wheatbeing choked by the cares and troubles ofthe world is very apt. ‘And some fell amongthorns. And the thorns sprung up andchoked them (Matthew 13: 7).

● Play the Shakespearian fool. Take time toremind the units about creative and inno-vative thinking, about having fun, aboutpermission to laugh. It is easy to skimp ontaking time to reflect and review whenthere is so much to be done. The dike hastoo many holes for me to take time tocount my fingers

It’s tricky growing up. Adolescence can bea time of great optimism, expanding horizonsand boundless energy. But there are timeswhen we all need a hug from mum and dad.After all they were there when it all began.

References

Carr-Gregg M, Shale E (2003). Adolescence: A guide forparents. London: Vermilion.

University of Leeds (2003) Practice Development Unitaccreditation criteria

Ryan, SD (2000). The politics of challenge – A moralvision and obligation. Statement of the CatholicConference on Bishops

University of Leeds (2003) Practice Development UnitAccreditation Criteria. University of Leeds.

JOHN BENTLEYJohn.Bentley@5boroughspartnership.nhs.uk

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