You need to remember the past in order to learn from it.

Re-creating the ‘Time to Care’ series for 2024.

One of my oddest experiences of working with NHS policy is the way in which things just get forgotten. Not just a small memory slip by a few people but COMPLETEY FORGOTTEN by nearly everyone. So that when you mention something that happened 20 years ago most people think you are talking about fairy stories rather than something that really happened to hundreds of thousands of people.

We are at a time when the NHS is in crisis. This crisis is, in part, made worse because as it develops leaders become stuck in the ways of thinking that helped lead to the crisis in the first place. The depth of it seems to make leaders find it hard to think outside of the tramlines of their thinking. There is something very human in this – because if it were possible to think in innovative ways the crisis would probably not have been so bad in the first place.

Today though I don’t want to discuss innovation per se, but the fact that it also seems as if leaders have come to see parameters, actually made by women and men in the past, as immutable. As if, for example, the current financial flows through the NHS are as unchangeable as gravity. The fact that the big changes of the past, were changes made by people like you and me is forgotten, But if people could change big things in the past, we really should be buckling down to do big things now.

The reality of history is that in the past people, lots and lots of them, did things that people in the present seem to think is just not possible.

For example, over the last year, following the Hewitt report on how to enhance the importance of ICBs, there has been some discussion about developing new financial flows. Some of this culminated in a report published by the NHS Confederation that I discussed in March.

During this period I have had probably hundreds of conversations (yes, it’s quite a life isn’t it?) about how we need to develop new financial flows. About how the crucial thing is not the current payment by results system but what results do you want from it – and how to construct a financial system to get them.

These conversations are always compassionate, people listen kindly to my thoughts, but I can see they think I’m a little crazed. The things that I am talking about changing are just, sort of, there.

And when I try and explain this to myself it’s as if the current way of financing the NHS crossed the Channel with the Romans. Caesar’s legions fight their way across Kent and cross the Thames to where Whitehall now stands and, when planting his standard, places next to it a scroll containing the current 2024 financial framework for the way in which the NHS finances its different services.

  • There will be a GP contract which will employ one group of doctors on a different basis from another.
  • There will be a block grant for some and a payment by results system for others.

(and all of this in Latin and alongside the dwindling capital programme – which I might say looked up a little later under Hadrian).

“Civis Romanus Sum!” he says

And if, 2000 years later someone suggests changing this – well they are trying to change an historical precedent of this longevity.

I apologise for the weak sarcasm. But what lies behind it is my fiercest personal belief that since human beings created these things in the recent past then yes, we, also human beings, can create something different.

If we can’t – all of us – get hold of this truth – we will end up constricted by the past. I will return to this in a few paragraphs.

So given that just over 20 years ago we created a financial system for how money flows around the NHS we can now create a new one. We can take charge of our own changes rather than continue to do what was decided 20+ years ago.

The theme of my last few posts was staff. And particularly how we work with staff to create a better employment experience. Today I want to link that thought with another which is usually felt to be opposed to staff involvement. The need to increase productivity.

Most productivity drives are experienced by staff as expecting them to simply do ‘more’, Given that they feel they are working flat out already, being expected to do more is felt by most members of staff to be ridiculous. At the moment, if you’re a GP, getting home before your kids get to bed is a life goal. A productivity drive in primary care sounds like the end of the line.

Given the importance of productivity improvement it would be vital to gain staff acceptance of any initial work.

I would therefore start with the experience about which every single member of NHS staff already has an opinion – the nature of waste in their workplace. My argument would be let’s start a drive towards better productivity with that shared experience of waste.

And that comes back to the theme of my earlier paragraphs. We have forgotten that less than 15 years ago, across the NHS, we have had a lot of productivity improvement work implemented by staff themselves. Increasing productivity. Toolkits encouraged staff to develop ‘their own time and motion’ work to eliminate waste, to give them ‘more time to care’.

Consider,

  1. a) the NHS really needs to improve productivity,
  2. b) all staff have clear ideas about waste,
  3. c) 15 years ago we had a series of tool kits to do this,

and

  1. d) if only we could remember that 15 years ago we were capable of asking staff what they thought was wrong.

we could improve productivity again.

If only

…. If only.

Beginning in 2007 the DH developed – starting with a product called the ‘Productive Ward’ – a series of staff-led work improvement programmes. I particularly remember visiting hospital wards where nurses had used the Productive Ward to collectively improve their time to care on their ward.

Each group of nurses initially focused on the waste they saw around them in the ward – much of which was the responsibility of their managers to solve.

Broken equipment left on the ward for months; the fact that everyone who purchased latex gloves always bought large, medium and small sizes. (The large ones rarely get used but that doesn’t stop them being purchased – I visited a number of wards where I was shown into rooms full of unused large gloves – with more still being ordered).

Nurses’ successes in improving their workplace were all placed on the ward notice board.

After that initial ‘time to care’ work the nurses turned to their own organisations. Most staff groups have clear ideas about how to improve their own workplace. Once they had some success with improving their environment the toolkits drove discussion about improving the way in which they worked. It was estimated that this improved their ‘time to care’ by 25%.

When discussing this with staff I remember saying that these were time and motion studies being developed and implemented by staff themselves and not by outsiders.  Nurses with their own clipboards.

The overall initiative was Releasing Time to Care, the NHS Productive Series, (Much of this site has been archived but could easily be made available by NHSE). At the time the Director at the Department of Health responsible for improvement (Jim Easton) described it as “probably the strongest product in the world for driving change in providers (of healthcare)”. The first in the series,The Productive Ward, Releasing Time to Care, was adopted by over 80% of English hospitals. It was well evaluated, and its implementation shown to deliver improvements in productivity, agency, and efficiency in many settings. It was adopted by healthcare systems globally including those in Australia Canada, Denmark, Ireland, the Netherlands, New Zealand, and the USA as well as in all the home nations of the UK.

NHS England has since taken down all the materials. Thankfully some other websites have kept it. Here is the toolkit for The Productive Ward, another in the series for Productive Community Hospitals.

I remember in 2010 I went to the west coast of the USA, and we did £1 million of business for the NHS selling the productive wards is to US hospitals.

In England the productive ward was implemented with the RCN which meant that this was an improvement in productivity, led by staff, was also supported by the unions.

So, the first thing we need to do is remember that we have done this before. The NHS did this itself. We need to return to that experience and learn from it.

Next, given that nearly all staff have clear ideas about waste we need to empower them with these tools we have just resurrected.

Of course, these aren’t the only ways we increase productivity, but they are a start.

2 Replies to “You need to remember the past in order to learn from it.”

  1. One of the most informative blogs l’ve seen in ages. Common sense dictates ‘don’t re-invent the wheel’ and this blog highlights how the NHS has a habit of doing just that. Let’s look at some of the innovative ideas of the last 10-20 years and bring them back into circulation. ‘Productive wards and Waste’ would be a cost effective start and we don’t need to don latex gloves to do it.

  2. Paul,
    My own experience of being involved with large scale educational change in the NHS between 1993-2006 influenced my thinking to include the following points.
    We were unsuccessful in creating cultural change at scale which often diluted radical innovation. These cultural changes along with the challenge to existing power systems failed. Our attempt to redesign workforce education and training for the whole workforce was skilfully managed out of the system by an elite network of senior managers in the DoH and beyond.
    Policy was iterated at national level and often attracted a consensus across the workforce eg Working Together/ Learning Together which introduced Lifelong Learning approaches into the NHS. The main challenge to its implementation emerged from those institutions and organisations who felt threatened by the introduction of new ways of learning in the workplace along with a national system to implement the new model education with its roots not in traditional seats of learning but in the community university model. You may remember the Polytechnics?
    My other observation was that we as so called change agents were ourselves still learning from on the job experience but we were not able to accelerate our learning and share this experiential learning with a growing community of people across the service. We needed to learn faster than a virus but we were too slow.
    To recap. Do we have a theory of learning that informs our practice(s) of change at mass scale ?
    Ed Rosen
    Education Adviser London Deanery/ British Postgraduate Medical Federation 1993-2001
    DoH Consultant on the implementation of Consultant Appraisal
    2001-3
    NHS University Head of Learning & Teaching 2003-05
    Director of Lambeth GP Food Co-operative

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