The role of ‘agency’ in making NHS performance management less destructive.

Last week’s post explored the problems caused by the clash between the immediate need of NHS staff – who require a period of calm and restoration to recover from extreme fatigue – and the pressure of the very traditional NHS style of performance management that will be deployed to reduce waiting lists by increasing staff workloads.

Put simply – if you simply shout exhortations to do more work at exhausted staff they will, if they can, very probably quit.

So, this week I want to explore two different themes that could be included in NHS performance management that might mitigate the damaging impact of its traditional approach.

At present too much ‘management of NHS performance’ revolves around simply chasing providers, noting down the numbers achieved, and combining this information with a set of assumptions in a conversation that begins with the question ‘How are you doing?’, and ends, ‘Is that all? You’ve got to better than that!’.

The practice of managing performance could be expanded to include those involved in the process providing some assistance to those doing the work. A conversation, not just about numbers, but also about thinking of other ways to do better. I would style that as managing performance by providing ‘assistance’ to service providers. I will develop this idea further in my next post.

In this post I want to develop the conversation around the idea of giving ‘agency’ to those providing services and how that could help to improve performance.

A year ago, when the pandemic hit, the stories emerging from all levels of NHS service provision were about how swiftly, in the midst of the crisis caused by the sudden dramatic increase in the need for health care, new ways of working were developed. About the number and range of staff who stopped what they had been doing for some years and started to contribute to patient care in ways that were different from before.

In hospitals this led to a sudden increase in the number of beds that could work with patients who needed intensive care – and indeed the nature of intensive care provision. In the second wave this was repeated.

In primary care, because of the danger of infections if people met, the switch to remote consultations was equally transformative. Primary care also provided safe health care in new ways.

All of this – and much more – happened because staff at the point of delivery worked out novel ways of providing services. More importantly their managers, and their manager’s managers, agreed these were good ideas, “so just do it”.

This was ground-breaking. A risk-averse management culture came up against a crisis where the risk of not doing something new was much greater than carrying on as before. Reports show that staff on or near the various front lines came up with innovations to provide good health care.

Recognising that staff who actually carry out a task over time have ideas for improving its execution, is only the beginning. Giving them the authority to make those changes is the necessary shift in power to make change happen.

This all comes under the idea of human ‘agency’. Providing and receiving care is, in every setting, a complex, mainly human process. Important machines are involved in care provision and they undoubtedly help a great deal; drugs and vaccines (especially at the moment) change the way in which health care is provided – but in all settings human interactions are involved.

Most of us  (‘us’ being the 20 million people who have had the vaccines) have felt that something special happened in our bodies when we were injected. But every vaccinated person I have spoken to has also mentioned something to the effect that “Everyone at the vaccination centre was so nice”.

Which, because this is a human interaction, means that staff involved in it know better than people several levels above them how to improve productivity.

About a decade ago I worked with the NHS National Institution of Innovation to help sell a toolkit that had been developed with the input of nurses to improve productivity on their wards. Called “Time to Care” it can be found on the NHS web site. It caused immense international interest, in particular on the west coast of America. There the NHS sold many of these kits explaining how wards could improve productivity.

The basic idea behind productive wards is very simple. The starting point is the premise (fact) that if you listen to the nurses on the wards and their immediate leaders as they talk about their work, they will give you multiple examples of waste which they know how to reduce. Waste is something that most front-line staff hate a lot more than their managers because they can see its impact on the time they have to care for patients.

I am not being idealistic and suggesting that every idea front-line staff come up with can be implemented, but what Time to Care found was that many can be. Essentially what this programme developed was the idea of nurses themselves being in charge of the time and motion studies to improve their outputs and productivity. It was not someone else holding a stopwatch and a clipboard saying – “Work harder” – it was the staff themselves. When implemented this work improved productivity by 20-25%.

The NHSE Improvement Hub has extended this series to a much wider range of primary and secondary care.

What would be the impact, in March 2021, of NHS performance management also asking – as they checked the numbers of each provider – have you asked your front-line staff how they can remove waste and increase productivity to improve the speed with which we can cut into waiting lists? And have you implemented these improvements across your organisation?

This would be asking exhausted staff for their opinion and their input. And asking them specifically to become agents of the improvements in the way in which they delivered services as the Covid crisis hit.

Ignoring the potential agency of tired staff whilst at the same time issuing a welter of performance management instructions would be a big mistake.

(Mind you, so is saying they are only worth a 1% pay increase).

But if performance management always asked how senior managers were empowering front line staff to improve their productivity – it’s highly likely “Time to Care” would increase.