How could we massively boost productivity in health & care? Part two. A summary of comments on my last post about "Productivity starts with people", co-authored for @BMJLeader. These come from across multiple social platforms. Five themes stood out: 1. Who creates productivity? Richard Wylde argued productivity cannot be done to people. Those closest to the work see the opportunities and barriers most clearly, given trust, support and space. Ian Carruthers said the NHS needs to give people permission and authority to fix obvious problems. Marion Dixon asserted that good leadership which supports staff to “change their world” really matters. Dr Sadia Khan contrasted “control” that yields compliance, and “psychological safety and agency” that yield innovation. Laura Yearsley described people choosing the improvement areas themselves, with learning as the strategy in place of a detailed plan, with people from surgeons to nursing assistants choosing to make time for the work within demanding jobs. 2. Permission, time and support: David Groom noted change cannot sit on top of the day job. People want to be productive and need permission, structure, time and senior support. Jonathan Sunkersing observed progress comes from modest improvements done consistently, which makes it accessible to everyone. As a leader, Lesley Parkinson would agree the improvement gap with the team and hold those conversations weekly. Anthony Lawton recalled a manager complaining he produced ten ideas a week, and a finance director who asked how many were good. 3. The conditions for professional judgement: @farhadali said that protocols and prescribed ways of working protect safety; leaving no room for judgement kills the capability productivity depends on. Sarah Jenkins reported the instinct was to hand “productivity” work to finance colleagues, when culture and psychological safety affect us all. Vijaykumar V said without trust and relationship we can do nothing. Jennifer Carroll described creating the conditions for people to do their best work and connect authentically. 4. Shift from managing queues and capacity crises to designing for timely movement of patients, information and decisions: Chris Cooper argued for adopting economies of flow and features of the on-demand economy. Mike Chitty wants managerialism and care to become more comfortable partners. Richard Ogden would concentrate on the bottleneck. Martin Silcock asked who looks strategically at pathways. John Mortimer found the professional taking the call and visiting the person used 14% fewer resources with better outcomes. 5. Who and what we count: Sharon Anderson pointed to family caregivers as a second workforce, invisible in planning and productivity measures, creating hidden work on both sides. Tina Patel Gunaldo wants the same emphasis on what is going well as on what needs improving. Sonya Cullington said sustained AI use can erode the cognitive conditions improvement needs. Farai Pfende cautioned that extra effort and workarounds can make a struggling system look productive. Thanks to all who commented.

If we want sustainable organisational change, which group is more important? (a) People who are active in response to the change (even if they are resistant); or (b) People who accept the change? Newly published research suggests (a); it is more important to get people active in change than it is to get favourable responses to it. Active dissenters/resisters/opponents are preferable to passive, seemingly accepting people who go along with the change. Many existing change frameworks focus on “valence”: the extent to which people are positive or negative about the change. This research highlights the importance of another dimension: “activation” - the energy or action level in people’s response to change - whether they are engaged, energetic & visible (active) or quiet, withdrawn, & non-participative (passive). The authors have created a four box framework called “the Change Response Circumplex Scale”. I’ve added some strategies for working with the different categories alongside their graphic. Active resistance is preferable to passive disengagement because it: -keeps the lines of feedback & dialogue open -surfaces important information & risks that passive compliance might hide -enables leaders to create psychological safety for diverse reactions to change. -Creates the conditions for long term engagement in change. Implications of this research for leaders of change: 1. Go beyond reducing resistance: Don’t just focus solely on minimising resistance or seeking passive agreement; aim to foster active, positive engagement from people -what the authors term “change proactivity.” 2. Understand engagement levels: Differentiate between passive acceptance, disengagement & truly active, positive support. Use the framework to understand people’s responses to your change initiative. 3. Create interventions accordingly: Disengaged people need approaches to increase involvement, passive assent can become active support & resistance can become constructive dialogue. 4. Leverage the value of dissent: Rather than viewing resistance solely as an obstacle, explore what motivates active dissent & use it as a resource for learning & adaptation. I appreciate this model because it challenges so much of the existing (dubious) advice for change leaders to “overcome resistance to change”. Instead we should work to activate engagement in change. The research shows that both high activation responses (change proactivity & change resistance) show the most promise for long term change engagement. Activism is what changes the world. There are two research articles about this framework. The 1st, from 2024, validates the framework (This is a version from Scrid so it is it accessible): scribd.com/document/89056213…. The 2nd, which sets the framework in a wider change context, is from 2025 & is attached to this LinkedIn post from Cheese Cheeseman: linkedin.com/posts/cheeseman…. By Shaul Oreg & Noga Sverdlik.

Three modes of organising for improvement: (1) Doing things well (2) Doing things better (3) Doing better things An organisational improvement strategy should focus on all three. Many organisations currently are overfocussed on (1) & (2) and under focussed on (3). This is risky because we can end up focused on improving the "wrong" or suboptimal things. The environment of change that we find ourselves in means that we have to focus increasingly on (3). It won't happen unless we build in the time & space for connection, collaboration, experimentation & learning into daily work. I adapted this table from content in "Improving quality in healthcare: questioning the work for effective change" by Murray Anderson-Wallace & Nick Downham. I really like this book, written by highly experienced practitioners: us.sagepub.com/en-us/nam/imp….