A thought experiment - getting serious about safe care in today’s NHS

A thought experiment. Experimenting in the abstract with the aim of getting off the wheel for a breath, generating some hard questions, challenging assumptions, thinking the unthinkable. Let’s go.

The premise

Safe reliable care is predicated on designing, operating and improving systems of care delivered by teams. Teams filled with trained, capable people working as one, focused on each other, the patient and thirsty to learn.

From this premise we get to some team design principles for delivering safe care:

1. Effective team working
2. Constancy of team membership
3. Capacity matched to demand

There is always more we could add to the list but for this experiment we have enough to play the game.

Today’s NHS workforce crisis is impacting on safe care, because the key design principles are broken:

1. Effective team working depends on respect and trust. This takes the right behaviours, actions and constant attention. You can call it culture, but that becomes a fog without substance. Respect and trust. Let’s stick with that. It is hard to root a team in respect and trust. We spend a fortune on hierarchy management and mediation when teams go into crisis and blood splatters the walls, metaphorically. It is even harder to sustain respect and trust when the people in the team keep changing and you never get to build relationships to build respect and trust. The team keeps changing because of vacancies, with gaps filled by agency and locum staff. Today’s growing workforce crisis.
2. There can’t be many teams across the land not reliant on locum staff across the disciplines but especially doctors and nurses. Every shift starts with new temporary people not as invested in the principles that drive an effective team. I generalise but bear with me. Services and teams are further troubled by churn. Staff on the way out, in the building but already checked out, and new people coming in - it takes time to learn how everything works, how people think, where you can get help without being ignored... Agency staff, locum staff, new staff, consume the productivity and efficiency of everyone around them. Imagine a hospital where one in four of all consultants are Locums. A terrifying fact. There is a constancy of high churn and constant reliance on the agency and locum journeyman.
3. With growing and unrelenting demand, some services will be working harder and faster. Demand exceeding capacity. Even with the vacancies filled with temps, the team is still not effective and whole. The substantive team members pay the price with sickness, and resignations. More gaps, more Locums. More churn. More instability.

So, how do we turn the design principles to be serious about safe care?

Restaurants

Restaurants illustrate the point.

A family run restaurant reliant on repeat customers rather than tourist passing trade will be acutely focused on retaining its customers. It’s focus will be quality and consistency. Customers know they will be served well, get good food, and will recommend the place. If staff numbers drop, front or back of house, the owners will reduce the number of covers - tables - right sizing capacity to staff to ensure effective delivery of good quality service and food. Less money but the long term view is quality for sustainability.

A tourist trap restaurant isn’t bothered by return custom. Volume is everything. Down on staff? Not a problem. Stretch the staff, Stretch everything. Revenue is everything. Get temp staff, whatever the quality. Profits at any cost. Tripadvisor might regulate behaviours but passing transactional trade is the business model.

Back to the NHS

The NHS talks of the patient at the centre of everything and safe care the priority but it is all about performance. The political pressures must be unbearable. Jobs are at greater risk for performance failures. Safe care failures risks jobs when the Daily Mail test is breached. I exaggerate a touch - it is a thought experiment...

On that principle, fill the vacancies with anyone, at any cost, and keep the covers open. Maximise capacity at any cost. Team working - good luck. Constancy - what’s that. Transacting the queues down is the priority.

There is that long term NHS workforce plan published earlier this year. It assumes that trying to flood the market with employees will fill the vacancies with substantive appointments, pushing out locum and agency staff. The plan will take a few years to do what it says on the tin, assuming most people invested in will stay regardless of deteriorating pay and working conditions. Dynamic complexity will yet again prove the fallacy of the linear thinking that fills the plan.

The experiment

Now imagine you choose to be serious about safe care. It really is the priority. You could start with right sizing the ward bed base to the substantive staff numbers. No more agency and Locums. That means closing off beds. The patients get the care they need and deserve. Care is safe and reliable. The staff get to do the job to the standard they know is possible. The staff work as a team, without having to oversee the agency locum, distracted by constantly over seeing and settling staff throughout the shift.

The consequences are several:

• Fewer patients get care over time
• Performance numbers take a hit
• Agency staff start worrying about jobs and income

If you keep this up long enough, and so do the surrounding providers, the journeyman agency and locum staff get the message. You care about safe high quality care. You care about your staff and team working. If they want to earn a living, they are going to have to become employees, become part of a team and deliver safe high quality care. The market shifts because you made the shift in priority.

More consequences:

• Agency locum costs drop
• Staff feel safe and work without burning out
• Churn drops

I can hear the screams - but the ED doors are open and where will we put all those patients? A reminder of a lesson from the doctors in training strikes. Consultants across the spcialities at the front door and on the wards making decisions resulted in hundreds of empty beds per Trust. Hundreds. It’s all about choices.

Phasing the experiment

The experiment choice seems binary - performance at all cost or safe care at all cost. It is after all a thought experiment.

Suddenly right sizing teams in ED and the wards might be a real experiment too far. Phasing down steadily might make for a steady market signal and shift towards more stable teams, better team working, safer care, and better patient experience and outcomes.

The positive consequences will be the same, it will just take a little longer.

Choices

We already make a choice. We accept the idea of patients waiting to be seen in General Practice, ED, and outpatients. The size of the queue a measure of resources invested and organised. Zero queue means just right or more probably over invested in capacity. Waiting a year waits means that’s what we have invested in and waiting is the price paid by the patient. The price could mean worsening physical and mental health.

This thought experiment is not about growing queues and damn the consequences. It is about passing the stated priority of safe care through an experiment that surfaces the primary importance of stable effective teams supported to do the work to the standard that they know makes a difference.

The experiment is deliberate linear thinking to surface the tangles. There are additional choices complicated by expectations, politics and the social contract.

If the ordinary punter really understood what it took to deliver safe care, the thought experiment might be more than just a thought.

X @Nadeem_Moghal

(Not a kiss, just that thing once called Twitter)

Notes:

• AI has has no hand in any of my writing.
• Happy to fix errors on notification.
• Hurtling through the tunnels of London - never a wasted moment