The changes enabled by freedom and trust in the Covid crisis

“We made changes in two weeks that would have taken two to five years BC”, explained David Amos, Director of People at Barking, Havering and Redbridge, University Hospital NHS Trust (BHRUT). BC means Before Covid-19. After Disruption is AD.

Or, as another NHS worker put it, “What has previously not been achieved in five years has now been achieved in five days.”

There is no doubt that things have been tough in hospitals. But there is also an up side. As one surgeon was quoted on Twitter, “we are all getting to do exactly what we’ve always wanted: be clinicians and use our judgement. See a problem, solve a problem, watch it catch on around the ICU. F**k the paperwork, f**k the regulations, just do the right thing.”

Freedom within Guidelines

It is the concept of Freedom within Guidelines writ large (though the guidelines would normally include following the regulations!) I have often asked organisations how quickly they could respond to change if they fully trusted their front-line staff, if they gave them the freedom to respond instead of requiring reports and various levels of approval.

What we have seen in the past three months is that, if organisations are prepared to trust their staff, then the answer is very quickly indeed.

Victoria Camp, from Caerphilly Council, explains how she responded to the need to match vulnerable people with volunteers. She designed a process flow, digitised it, allocated roles and met the needs of 1,500 people with 600 volunteers.

“I didn’t get sign off, I didn’t write a report, we just delivered as a team, focussed and swiftly. It was a dream!”

“Coronovirus has been a system laxative”

That was one comment from a Tower Hamlets health worker. Others talked about how “we went paperless overnight”, how “virtual consulting is now the norm” and, for those outside the NHS, we have all shifted speedily to home working..

Of course a key element has been the community response. “Covid mutual aid groups got off the ground fastest”, commented Meera Kateida, a QI Clinical Lead in Tower Hamlets, “despite having no budget at all.”

“We had one Deputy Head who found he had 1,400 pies and needed rid of them by 4pm. He posted on the covid mutual aid group site, got 2-3 replies and by the evening the Whitechapel Mission had distributed them all to those in need.”

There are 1,001, or probably a million and one, similar stories across the country of what has been enabled by the crisis.

Adapting as you go

There has been much more flexibility. Christina Rennie, of University Hospital Southampton, explains that previously there was a lack of resource, no project manager available, for tracking of patients in the outpatient system. With the new agility a triage tool was put into the electronic patient system. “It was the most amazing development. Previously we had loads of patients delayed in the system and not easy to track, putting them at risk of harm.”

This was done in two weeks. “It wasn’t perfect initially. I am the hospital lead for patient safety and the ability to risk rate patients was missing. The basics were there and we could use it, we fed back, the system was adapted rapidly and now we have something that people can use and allows us to track and prioritise patients appropriately.”

“Many things have happened in this short space of time that we’ve been wanting to do for a long time. The new approach is to learn and adapt as we go.”

Trust people to use their judgement

The common thread in the accounts from many different organisations is that – to enable things to change speedily – the levels of hierarchy and approval had to be removed. People were instead trusted to use their judgement.

The classic example of where this has always been the cease is the Buurtzorg care organisation in the Netherlands. They have saved around 30% of overhead by having no managers at all, no levels of approval required. Nurses work in teams of 10 to 12 and, knowing the values they work within and understanding the key metrics, deliver better care at less cost than more hierarchical organisations.

What has been fascinating in the last two months has been how many workplaces have been able to move fast and change. And the NHS is no different from many other organisations – public, private and charity - in requiring a level of approval that implies a lack of trust.

No Going Back

As David Amos added, “the pendulum of leadership has switched to the front-line staff. And we want it to stay there. Instead of committees and hierarchy we have multi-disciplinary teams, moving swiftly in new and different ways, implementing change in real time.”

But the big question that everybody I talk to in the NHS asks is whether the new freedoms and rapid response will continue. Magda Smith, Chief Medical officer at BHRUT, believes it will: “It is a new NHS. It is a new BHRUT. There is no going back”. Check out their 2 min video here.

But some are already bringing back the old ways: “A few weeks ago”, explains one front-line employee, “I was trusted and empowered to design and roll out a process affecting huge numbers of customers and staff mid-crisis with few approvals required. In contrast, just a few days ago I had to include four levels of management in a decision making process, which had already been reviewed by every senior officer in the organisation.“

Will, AD, we go back to the rigid systems, and lack of trust, that got in the way of progress in the past?

Or will we learn from this crisis, remove those levels of approval and give front-line staff the freedom to decide for themselves?

What examples have you seen of speedy implementation due to freedom for front line staff?