helping govt learn

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REPORT BY THE COMPTROLLER AND AUDITOR GENERAL | HC 129 Session 2008-2009 | 27 February 2009

Helping Government Learn


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The National Audit Oice scrutinises

public spending on behal o

Parliament. The Comptroller and

Auditor General, Tim Burr, is anOicer o the House o Commons.

He is the head o the National Audit

Oice which employs some 850 sta.

He and the National Audit Oice are

totally independent o Government.

He certiies the accounts o all

Government departments and a wide

range o other public sector bodies;

and he has statutory authority to report

to Parliament on the economy,

eiciency and eectiveness with

which departments and other bodieshave used their resources. Our work

saves the taxpayer millions o pounds

every year: at least 9 or every

1 spent running the Oice.


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LONDON: The Stationery Ofce

14.35

Ordered by theHouse o Commons

to be printed on 25 February 2009

Helping Government Learn

REPORT BY THE COMPTROLLER AND AUDITOR GENERAL | HC 129 Session 2008-2009 | 27 February 2009


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This report has been prepared under Section 6o the National Audit Act 1983 or presentationto the House o Commons in accordance withSection 9 o the Act.

Tim Burr

Comptroller and Auditor GeneralNational Audit Ofce

23 February 2009

The study team consisted o:

Henry Broughton and James Young romthe National Audit Ofce, working withChris Lane, Indra Morris, Elliot Shaw andDavid Barley rom Accenture, under thedirection o Jeremy Lonsdale

This report can be ound on the National AuditOfce web site at www.nao.org.uk

For urther inormation about theNational Audit Ofce please contact:

National Audit OfcePress Ofce157-197 Buckingham Palace RoadVictoriaLondonSW1W 9SP

Tel: 020 7798 7400

Email: [email protected]

National Audit Ofce 2009


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PArT ONE

Organisational learning in goernment 9

PArT TWO

Case Examples in organisational learning 15

PArT THrEE

What departments and the centre of 38

goernment are doing to spport learning

APPENdicES

1 Methodolog 48

2 Self Assessment Framework 50

glOSSAry 54

Photographs courtesy o Alamy.com

CONTENTS


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4 HELPING GOvERNMENT LEARN

Why learning is important

1 To achieve value or money in public services,departments need to learn rom success and ailure.

The Comptroller and Auditor General and the Committee

o Public Accounts have examined many instances

where major programmes and projects have been either

rustrated, or severely hampered, by ailure to take on

board lessons rom their own past experiences or those

o others. The Cabinet Oice and other organisations at

the centre o government have also concluded, ollowing

their own reviews, that government departments need to

improve their capacity to learn. For example, a summary

o recent Capability Reviews argued:

the Reviews have shown that there is scope for

improved learning and sharing across departments and

their delivery chains. It is important that good practicespreads across the Civil Service.

2 This report examines how departments could be

better at learning. Learning occurs in many ways. Sta

can gain insights and experience rom simply doing their

work, whilst training can help in developing new skills

and knowledge. Feedback rom customers and timely

analysis o complaints can help drive improvements, and

comparisons with the actions o other organisations can

act as a stimulus to do things in new or innovative ways.

Departments can also beneit rom advice and guidance

rom central bodies such as the Cabinet Oice andHM Treasury, as well as rom the insights provided by

evaluations, audits and scrutiny exercises.


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5HELPING GOvERNMENT LEARN

3 Organisations that are successul at learning tend

to share certain characteristics. Above all, their senior

management actively support and encourage learning,

and their sta are incentivised and given time to think

about how to improve personal perormance and that

o their organisation. Accumulated knowledge is readilyaccessible and acted upon to avoid similar mistakes

being repeated.

How we undertook this study

4 We gathered evidence or this report in a number

o ways. We examined 11 case examples o learning in a

wide range o public sector settings. The case studies were

selected because they provided examples o where time

and resources have been devoted to learning, leading to

improvements in service delivery. The examples in Box 1on pages 6 and 7 provide important learning points that

are transerable across departments and should signal to

those responsible or leading change in departments that

greater time and eort devoted to learning can help secure

value or money in the delivery o public services.

5 The report also considers why learning is not always

widespread, based on interviews across government and

a survey o all central departments. It examines the main

barriers to learning and the role that the departments

that make up the centre can play in supporting the

development o organisational learning. We also drewon a wide range o other evidence sources, including a

literature review and consultation with a panel o experts

and practitioners in leading organisational learning in the

public sector.

What we ound

6 There is scope for leaders in departments to give

greater priority to learning. Opportunities include, or

example, giving it a higher proile at management boards,

and including commitment to learning in competency and

assessment rameworks o senior sta. Nearly 90 per cento management boards do not discuss learning rom

their activities requently, a third do not have a member

o the board responsible or reporting on organisational

learning, and only hal o departments have contribution

to organisational learning within their competency

ramework or senior civil servants.

7 The main barriers to learning experienced by

departments are silo structures, ineffective mechanisms

to support learning, a high turnover within the

workforce and a lack of time for learning. Learning

successully requires a shit in how people approach their

day to day work, and devoting time to learning needs tobe valued through greater use o incentives and rewards

in departments.

8 Programme and Project Management Centres

of Excellence have yet to realise their full potential to

contribute to organisational learning. For example,

only a quarter o Centres o Excellence prepare an

annual report on the lessons learnt in their departments

experience o delivering programmes and projects, and

the majority o Centres report to their departmental board

sporadically or not at all.

9 Central departments, in part icular, the Cabinet

Office and the Treasury, have an important role to play

in promoting learning across government. Their work

gives them insight into what works well and where

common causes o ailure lie. While departments are

aware o the support the centre provides and value its

role in establishing and supporting cross-departmental

networks, they report that these organisations need to

develop a better understanding o departmental delivery

issues, and there is scope or a rationalisation o the

guidance and support tools provided.

10 Departments find cross-departmental networks

and communities of practice most valuable to

supporting learning. The developing proessional

networks, some supported by the centre, such as the

Chie Technology Oicers Council and the Change

Directors Network, provide a good platorm or the

sharing o knowledge and experience.


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A ePasspots were sccessfll introdced in 2006, meetingthe uS isa waier deadline, while at the same time keeping

within existing serice delier agreements. The Identitand Passport Serice learnt from its tramatic experienceof introdcing new sstems in 1999, and made good seof the disciplined application of programme and projectmanagement processes.

Ke essons:

n Those leading projects need to be fll committed tothe rigoros application of existing programme andproject tools.

n Setting expectations for management teams to incorporatelessons learnt into their planning and delier helpsaddress the risk of knowledge being acqired andshared, bt not applied.

B The Potve Wa poamme in hospitals has generatedsome encoraging earl reslts. The NHS Institte forInnoation and Improement has seen significant redctions inthe time taken to dispense drgs to patients, patient handoertimes and meal wastage, as well as fewer complaints.

Ke essons:

n Learning initiaties work best when the meet geninedemands from the frontline.

n Learning gidance and tools work best when the aredeeloped with, rather than simpl for, sers.

c The oerall response to the 2007 otbreak of Foot anMoth dsease was sccessfl, with performance, taken as awhole, mch improed when compared to the 2001 otbreak(particlarl contingenc planning), with man of the lessonsidentified from the earlier otbreak haing been acted pon.

Ke essons:

n Continit in ealation and inqir teams enhanceseffectieness in learning from reiews.

n Learning gained in one department can be applicableacross goernment as a whole and shold be shared.

d The Parliamentar and Health Serices Ombdsmansannal report identifies that there is considerable scope for

departments to ean moe fom ompants. The Departmentfor Work and Pensions, health and social care organisations,HMRC and the Independent Police Complaints Commissionhae sstems to learn from complaints, bt in some casesbetter coordination wold enable lessons to be appliedmore effectiel.

Ke essons:

n Learning from complaints happens best when there

are sstems to captre and analse what peopleare complaining abot, thereb drawing otsignificant themes.

n If complaints sstems are too complicated, or if peoplefeel their complaint will not make a difference, the arelikel not to complain, and hence their insights into sericeproblems will be lost.

E The Department for International Deelopment has initiatedsstems and processes that help it ean fom staff an ts

we seve eve han for tackling AIDS and HIv.This learning has strengthened the HIv and AIDS strateg,helping to target resorces more effectiel and strengthen

partnerships with non-goernmental organisations.Ke essons:

n Learning from all partners across the delier chain iscritical to the deelopment of an effectie strateg.

n Intranets can proide an effectie means for sharinginformation and learning, particlarl where organisationsare geographicall dispersed. Howeer, this learning ismade more effectie b bringing staff together as well.

F The capabt Bn Poamme brings together peoplewith releant expertise from different departments to tacklecross-goernment isses. In this wa departments receiespport and challenge from teams with broad and in depth

experience from across goernment. The first pilot, whichfocsed on eidence based polic making at the Departmentfor Innoation, uniersities and Skills, has helped thedepartment to deelop new and innoatie approaches.

Ke essons:

n Bringing together people from different departmentsbroadens and deepens the pool of knowledge andexperience, enhancing learning.

n Cross-goernment initiaties work best when there is awell designed and strctred process that proides aplatform for learning and knowledge transfer.

g HMrcs Anes an daons initiatie allows front line staff topitch improements to bsiness processes to the managementboard. The scheme cost 2.5 million to set p and has1 million annal rnning costs, bt is designed to achiee aminimm retrn on inestment of 110 per cent oer two ears.

Ke essons:

n Senior leaders championing and spporting learninginitiaties is essential if staff sggestion initiaties are notto be seen as jst a gimmick.

n Linking initiaties to a measrable retrn on inestmenthelps bring legitimac and cltral change, deelopinggreater entreprenerial spirit.

BOX 1: cASE EXAMPlES OF iNiTiATivES TO ENcOurAgE lEArNiNg


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H The unte States Jste depatments Bea of JsteAssstane n oaboaton wth the cente fo cot

innovaton (a non-ovenmenta oansaton) has broghttogether law enforcement officials from across the unitedStates to condct candid assessments of what is working,and what is not working in the united States criminal jsticesstem. Leaders proide grant mone for new experimentsacross the jstice commnit to strengthen performance,informed b these learning rond tables.

Ke essons:

n Learning from failre reqires a commitment to creatingopportnities where problems can be discssed openlwithot resorting to finger pointing and defensieness.

n The challenge of moing towards this leel ofopenness within pblic sector organisations shold not

be nderestimated.

i Ogc gatewa evews are considered b departments to beeffectie in proiding external challenge and inpt to projectand programme delier efforts. Oer 2,500 reiews haebeen completed to date. The reiews hae been a catalstfor the newl established Major Projects Portfolio report,which is gathering together the ke themes emerging fromthe top 40 major goernment projects and programmes andGatewa reiews.

Ke essons:

n When taken together, reiews and ealations of a largenmber of indiidal programmes can inform wider

decision making and learning across departments.

n Central bodies sch as the OGC hae a pool ofknowledge abot what works well and where risks todelier lie. Departments hae mch to gain from actielseeking and learning from sch eidence.

J The Beaon Sheme has been effectie in identifingand sharing good practice across local goernment.

Sixt nine per cent of those who attended a Beacon eentimplemented at least one change the attribted to theirengagement with the scheme, and the scheme has boostedconfidence and delier across local goernment.

Ke essons:

n Acqiring the right knowledge is a strategic task; it rarelfalls into an organisations lap. There is ale in reflectingon where knowledge gaps exist and how these canbe filled.

n Learning from others works best when learning is adaptedto local conditions.

K Paamenta stncondcted b Select Committees is a

major component of the external ealation of goernmentdepartments. For example, the Science and TechnologCommittee report on the use of Science in InternationalDeelopment Polic sered to raise the profile of the scienceagenda across goernment. The 2005 Committee of PblicAcconts report Achieving value for money in the delivery ofpublic services, drew together learning from the Committeeswork from oer ten ears of scrtinising goernmentprogrammes, projects and initiaties.

Ke essons:

n Focsed and timel inqiries which address ke issesfor a department can hold considerable ale where thecommittee and department interact and reflect on findings.

n Examples marshalled from across goernment illstratehow inhibitors to efficienc and barriers to effectienessare often similar in natre and their associated lessons arehighl transferable.

BOX 1: cASE EXAMPlES OF iNiTiATivES TO ENcOurAgE lEArNiNg continued


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Conclusion on value or money

Past reports by the National Audit Oice, the Committee o

Public Accounts and others have identiied ailures in the

delivery o public services that could have been avoided i

more learning had taken place. As our case studies show,there is eective learning in departments, but overall the

evidence also indicates that learning is not yet suiciently

embedded within departments working practices, nor is it

prioritised as much as it should be. Learning oten occurs

ollowing a crisis or high proile ailure, but departments

will be more eective at learning when it becomes a more

habitual aspect o everyday working practice. Until then,

learning within departments will be constrained and ailures

will continue to happen, leading to avoidable waste,

ineicient practices and ineective services.

Recommendations

i Four-fifths of departmental management boards

discuss how the organisation is learning only

sometimes or rarely, and only two thirds have

a member responsible for organisational learning,

or a strategy linking learning to the delivery of

business objectives. Management boards should

assess their organisations current status in terms

o capability to learn rom itsel and others, using

either our sel-assessment checklist (Appendix 2)

or a similar method, as the basis or a structured

discussion to identiy strengths and weaknesses,

and benchmark themselves against good practice.

This analysis will allow departments to identiy

actions or improved organisational learning.

ii Much learning in government occurs following

large projects, initiatives or crises, but to be

more effective, learning needs to become a part

of day to day practice. Encouraging learning as a

routine element o an organisations work requires

departments and their sta to change behaviours.

Box 2 highlights a number o ways o shiting the

culture within departments.

iii There are few incentives to encourage staff to

devote more time to learning and reflection on

what has gone well or not well with their work.

Nearly half of departments do not have learning as

part of their competency framework for senior staff.

Departments should build learning into their reward

and incentives schemes to communicate more clearly

the value o learning and create the expectations

that teams will draw lessons rom their experiences.

Departments should reward those who are seen to

demonstrate the types o behaviours summarisedabove, and they should include contribution to

learning as a core competency against which Senior

Civil Servants are appraised.

iv Departments find much of the support and

guidance from the centre useful, but are confused

as to which units and organisations they should

approach. The Cabinet Oice and the Treasury

should build on the Compact agreed with

departments in 2008, by translating its principlesinto a clear, timetabled programme o action.

The objectives should be to create a streamlined

centre which is able to justiy its interventions on

business grounds and develop ways o measuring the

added value o central initiatives.

v There has been a proliferation of toolkits, guidance

and other products to help government learn.

These have been useful but there is a danger

of guidance overload. Led by the Civil Service

Steering Board, the centre should rationalise the

guidance and support on oer, based on a robustassessment o what departments ind most useul

and eective. The National Audit Oice will also

review the toolkits, guidance and support it oers to

departments in the light o this conclusion.

Ke was to shft epatmenta tes towas eann

1 Make staff feel it is safe to speak p abot failre and newideas, for example, b haing discssions abot specificproblem projects.

2 Gie staff sfficient time to learn and reflect on the wa thecarr ot their work and how it cold be done better.

3 Encorage the sharing of knowledge within theorganisation and discorage knowledge hoardingb teams.

4 Reward the generation of new ideas and an inqiringapproach, as well as the sccessfl completion of projects.

5 Encorage face to face collaboration throgh networks andthrogh training in team skills.

6 Instittionalise the sstematic reflection on performance afterprojects, een if it means delaing moing on to the next

project for a while.

7 Make sre that learning from consltants is captred beforethe end their contact with the organisation, and incldeknowledge transfer in the terms of the contract.

8 Acknowledge that work processes are constantl eoling,and that small improements and constant experimentationare to be expected.

9 In commnicating the ale of learning actiit to staff, selangage that is most likel to appeal to those inoled.

BOX 2


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1.1 This report examines the dierent ways in which

departments learn rom their own activities and

experience, and rom those o others, and considers howthat understanding can be used to improve the delivery o

public services.

1.2 Recent years have seen signiicant changes in how

departments deliver services to citizens. Many public

sector operations or example, purchasing car tax

or iling an income tax return are now delivered

electronically, whilst seeking a job involves call centres

operated by Jobcentre Plus. Other services are handled in

partnership with private or voluntary sector organisations.

These changes have been made alongside eorts to

achieve greater eiciency and value or money in theprovision o public services.

1.3 Continuous improvement in the public sector will

require innovative approaches to delivery, much o it

based on IT-enabled programmes and projects, and

is likely to involve outsourcing and decentralisation.1

As Government reviews have concluded (Box 3), to make

these changes and manage the risks associated with their

implementation, government departments and agencies

will need to learn rom their own experiences and those

o other organisations. They also need to ind ways o

capturing the learning gained by external suppliers so thatit is not lost to government.

1.4 Past reports by the Comptroller and Auditor General

and the Committee o Public Accounts have examined

problems with projects and programmes, and with policy

implementation. In many cases, these problems could

have been avoided i lessons had been learnt rom the

past. In 2005, the Committee expressed concern about

the ailure to apply more widely lessons learned in one

part o the public sector and about the repetition o

mistakes, even ater the causes have been identiied.2

Such shortcomings include the ailure to learn rom goodpractice identiied by others (or example, the National

Audit Oice and the Oice or Government Commerce

agreed Common Causes o Programme and Project

Failure3), rom users and other stakeholders or rom past

experiences (Box 4 overlea).

Organisational learningin government

govenment epots that emphasse the mpotaneof eann

The public service must become a learning organisation.It needs to learn from its past successes and failures. It needsconsistently to benchmark itself against the best wherever that isfound. White Paper Modernising Government(1999)

A learning to learn culture: within which change is continuousrather than spasmodic and there is a commitment to learnfrom anyone who does something better inside or outsidethe organisationSnningdale Institte, Evaluation of theCapabilities Review Programme(2007, p33)

The Capability Reviews have shown that there is scope forimproved learning and sharing across departments and theirdelivery chains. It is important that good practice spreadsacross the Civil Service.Capability Reviews Tranche 2:

Common themes and summaries (2006)

The Cabinet Office should also share best practice fromacross Government with Departments that will benefit from itChakrabarti Reiew, Role of the Cabinet Office, (2007, p7)

Those responsible for public service delivery must also learnthe lessons of open innovation and adopt innovative solutionsfrom the private and third sectorsInnovationNation WhitePaper (2008)

BOX 3

1 Excellence and fairness: Achieving world class public services. Cabinet Oice, 2008. See also Service Transformation: A better service for citizens andbusiness, a better deal for the taxpayer. HM Treasury, 2006.

2 Achieving Value for Money in the Delivery of Public Services, Report by the Committee o Public Accounts; 17th Report, Session 2005-06.3 Source: www.ogc.gov.uk/documents/Common_causes_o_ailure_V1.0.doc.


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1.5 The beneits or eective policy delivery o learning

rom past experiences can be seen in other reports.

For example, the successul roll out o the new Jobcentre

Plus oice network (one o the largest public sector

projects o recent years), which came within its 2 billion

budget, was partly due to eective learning. The lessons

rom the roll-out o 225 initial oices signiicantly

improved the eiciency o the delivery o the overall

project by leading to the creation o a core management

team and appointment o a senior responsible oicer, and

to the establishment o a clear understanding o roles and

responsibilities o key stakeholders.4

Exampes of the onseqenes of fan to ean n the eve of majo poammes an pojets.

BOX 4

th dlays Amsrg h 2005 Sgl Paym Shm eglaPb Aonts commttee Fft-ffth repot of Sesson2006-07

The Committee conclded that:

The single payment scheme was not a large grant scheme but

the Departments deliberate choice to implement the most complexoption for reform (the dynamic hybrid) in the shortest possibletimescale (in year one of the new scheme), its decision not toimplement a de minimis claim and the need to accommodate46,000 newly eligible claimants, led to a series of riskswhich individually would have been severe but collectivelywere unmanageable

and therefore:

Given the history of implementing government informationtechnology programmes, and in view of the wider changes beingattempted, it would have been more sensible to trial the scheme inthe first year and implement fully in year two.

chl Suppor Agy: mplmao of h chl SupporRformsPb Aonts commttee Tht-seventh repot ofSesson 2006-07

The Committee fond that:

The reform programme was ambitious and its managementshowed a lack of realism in both planning and execution.From the outset, the development of new IT systems and telephonyarrangements carried a high level of risk because of their size andcomplexity, coupled with a substantial business restructuring at atime when the Agency was already struggling.

And:

The Department spent 91 million on external advice on the

design and implementation of the Reforms between 2001-05,which the departmental financial management system could notbreak down by supplier. It has now implemented a new systemwhich can interrogate expenditure by supplier. In addition,the Department needs to follow the recommendations outlined inthe Committees report on the Use of Consultants. In particular itscontracts with consultants should include well-defined outputs andthe intended benefits of the work.

th naoal Programm for it h nHSPb Aontscommttee Twenteth repot of Sesson 2006-07

The Committee conclded that:

The Department has much still to do to win hearts and minds inthe NHS, especially among clinicians. It needs to show that it can

deliver on its promises, supply solutions that are fit for purpose,learn from its mistakes, respond constructively to feedback fromusers in the NHS, and win the respect of a highly skilled andindependently minded workforce.

th allao of Bsr Aommoao crPb Aontscommttee Twent-ffth repot of Sesson 2007-08

The Committee reported:

The strength of opposition to the proposed accommodationcentres from national refugees groups and local resident groups,which was identified during the passage of the Nationality,Immigration and Asylum Act 2002, was not fully reflected in thebusiness case for Bicester. The business case also did not take

into account the potential adverse impact on cost and deliveryarising from a protracted planning delay. The decision by theHome Office to sign the contract with its preferred bidder beforecompleting the outline and detailed planning processes increasedthe risk of nugatory expenditure.

The lessons to be learnt from Bicester have wider application togovernment bodies planning innovative projects. These lessonsinclude: the need to strengthen corporate governancearrangements where consultants are engaged at an early stage,to coordinate policy changes in different parts of an organisationtogether with consideration of external events, and to increase theeffectiveness and scope of consultation with the local communityand other stakeholders.

4 The roll-out of the Jobcentre Plus office network, Report by the Comptroller and Auditor General, HC 346, Session 2007-08.


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1.6 In their report, the Committee o Public Accounts

concluded that the Agency had learnt lessons rom early

diiculties, and that:

The successful delivery of the programme can be

attributed to sound governance, intelligent use of existingguidance and external advice, and strong support from

the leadership of the organisation. A critical factor was the

consistent senior management team, who between them

had over 100 years of front line operational experience in

the Agencys business. A willingness to revise the approach

to the project as roll out proceeded was also an important

factor in success. The successful project management

approach provides important lessons for other public

sector bodies undertaking major procurement and change

projects of this kind.

1.7 Other examples o success brought about through

close attention to lessons learnt are set out below (Box 5).

What do we mean by organisational learning?

1.8 Our review o the literature on organisationallearning has inormed our understanding o the actors

that shape the way in which departments and agencies

learn.5 Organisational learning is chiely about changing

behaviour to achieve improvement. It is a continuous

process that includes learning rom within a department

(rom, or example, experimentation or rom the

experience o past success and ailure), as well as rom

outside (rom the experience o other departments,

agencies and organisations in other sectors).

Exampes of poamme an pojet sess fom eann

BOX 5

Effectie se of accmlated knowledge

updating and testing contingencplans rigorosl

Adaptable processes throgh stafftraining and innoatie IT sstems

Listening to external adice

Following recommendations b the Committee of Pblic Acconts, after 2002, PFI contractsproided for pblic athorities to receie 50 per cent of the gains from debt refinancing insbseqent contacts and 30 per cent of the gains in preios contracts which had been letwithot refinancing gain sharing arrangements. In 2008, a change was made wherebthe pblic sector share of refinancing gains, from debt refinancings of new contracts letwhilst the financing markets remain ncertain, cold be p to 70 per cent. The refinancinggain sharing arrangements since 2002 hae ielded gains of arond 200 million fordepartments. The deelopment of the programme was de to examination of existingknowledge, inclding a Treasr Taskforce and OGC Best Practice gidelines, as well asthe Gatewa reiew process.1

The Department for Enironment, Food and Rral Affairs has learnt from preios mistakesmade in the Foot and Moth crisis in 2001and has deeloped a contingenc plan that isbeing tested and pdated continosl to accont for new sitations. These worked moreeffectiel in 2007 (see Case C in Part Two).2

uK visas had to respond to an increasing demand for isas (demand had increased boer 33 per cent in fie ears) and a rapidl changing polic enironment that demandedgreater efficienc. The Agenc achieed efficienc improements in the delier of the isaserice b implementing measres to streamline its working practices, sch as adaptingwork processes to handle applications onl once, and rigoros staff training.3

The ePassport programme was deliered with mixed teams of specialists from insideand otside of the ciil serice. The programme delier team drew extensiel onexternal learning and adice in programme and project management in technicall

demanding areas, to delier the programme sccessfll, while keeping to existing sericedelier agreements.4

NOTES

1 NAO and PAC reports on PFI contracts and refinancing can be downloaded from the NAO website http://www.nao.org.k/pblications.

2 Foot and Mouth: Applying the Lessons, Report b the Comptroller and Aditor General, HC 184, Parliamentar Session 2004-05.

3 Visa Entry to the United Kingdom: The Entry Clearance Operation, Report b the Comptroller and Aditor General, HC 367, ParliamentarSession 2003-04.

4 Identity and Passport Service: Introduction of ePassports, Report b the Comptroller and Aditor General, HC 152, Parliamentar Session 2006-07.

5 Available at http://www.nao.org.uk/publications.


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1.9 Organisations that are successul at learning tend to

share certain characteristics (Box 6). Above all, they have

a culture where learning is prioritised by their leadership,

and where sta are incentivised and given the necessary

time to learn and to think about how to improve personal

perormance and that o their organisation.

1.10 We have adapted the ollowing deinition o

organisational learning:

in the public sector [organisational learning] can

be regarded as the ability of an organisation to

demonstrate that it can learn collectively by applying its

knowledge to the policy process and to the delivery of

policy implementation.6

1.11 This deinition highlights that learning is a collective,

rather than simply an individual, process. It also highlightsthe signiicance o knowledge being used or a purpose,

rather than simply collected or stored, and indicates that

learning is linked to change in departmental activities.

The main sources o learning

1.12 The main sources o learning in the public sector are

shown in Box 7, which draws on our review o relevant

literature and emphasises the diverse nature o possible

inluences. Responsibility or making use o these sourceso knowledge and promoting learning is widely dispersed

within organisations. For example:

n individuals gain insights and experience rom simply

doing their work, and derive new knowledge and

skills rom training;

n policy teams, working together, gather inormation

as they develop and maintain policy initiatives;

n central teams within organisations are oten tasked

with examining how to bring about change, and

human resource and training teams ocus on

developing skills; and

n it is the responsibility o management boards to

make sure that their organisations are learning

continuously, and to monitor how successully this

is happening.

Our approach

1.13 To examine organisational learning in departments

we examined our key areas leadership, people,

inrastructure and processes. For learning to become

part o an organisations culture and to lead to enhancedperormance, each o these our elements need to be in

place. It is not enough, or example, simply to introduce

a new IT system or process to share learning i sta

are not suiciently trained and incentivised to use it.

Senior management support or learning will not be

enough i there are no eective methods or capturing

the knowledge secured rom evaluations and research.

Key aspects o each area are:

Leadership

n

There is a commitment to learning as a criticalactor in successul delivery, with a recognition that

learning needs to happen on a day to day basis.

n Leaders act as role models in championing learning,

or example, by attending events and activities that

promote learning.

Ke haatests of a eann oansaton1

n Leadership prioritises learning

n A willingness and abilit to change behaior

n An openness to learning from others and actiel

seeking lessons that hae arisen from the exection ofsimilar actiities

n Sstems that spport the sharing of knowledge andlessons learnt

n Internal cstomer/client relationships betweenorganisational nits which feed mtal adjstmentand adaptation

n A cltre and climate which encorages responsible, wellmanaged experimentation

n Reward sstems that encorage learning behaior

BOX 6

NOTE

1 Adapted from Pedlar, M., Brgone, J. and Bodell, T. (1991)The Learning Company.

6 Adapted rom Common, Richard (2004) Organisational learning in a political environment, Policy Studies Journal, 25 (1): 35-49.


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PART ONE


People

n Sta are given the time to relect on their own

experience and that o others, in order to improve

uture perormance.

n Sta are incentivised and rewarded through, orexample, appraisal and pay schemes, to share their

knowledge, and to make use o the knowledge

o others.

Inrastructure

n There are departments or units within organisations

with the role o supporting and developing learning.

Their eectiveness is evaluated systematically.

n Systems (such as databases and other IT applications)

are in place to enable the storing, sharing and

utilisation o knowledge and learning. Sta are

trained and supported to make use o these systems.

Process and methods

n The use o proven programme and project

management tools is part o the organisational

culture; sta are expected to use them and are

trained to do so.

n Drawing on lessons learnt and good practice is

documented and recorded as the key irst step to any

programme or project.

BOX 7

Soes of eann fo epatments

Soes of eann

Internal resorces and experience

Citizens and consmers

Partners, rials and comparators

Top-down direction, control and spport

Critiqes, adice and media

Testing interactions, crises and reiew

Exampes

n Staff experience of doing their job and dealing with cstomers on the front line

n Training

n Knowledge of past projects and policies

n Cstomer insight, inclding research and feedback from serice sers

n Complaints

n Piloting of projects

n use of contractors

n Secondments

n Cross-organisational knowledge sharing throgh professional and other networks

n Benchmarking and other comparisons with similar organisations

n Cabinet Office and Treasr adice and gidance

n Centrall set rles for propriet, hman resorces and organisational management

n Disseminating knowledge of what works (e.g. Prime Ministers Delier unitperformance monitoring and feedback, and problem soling within departments)

n Parliamentar oersight, especiall select committees

n Stakeholder consltations

n Media scrtin

n Academic reiew and comment

n Sstematic learning from mistakes and sccesses

n Ealation

n Departmental crisis management

n After Action Reiews

n Capabilit reiews

n Adit

Source: Adapted from Gilson, Dunleavy and Tinkler (2008) Organisational Learning in Government Sector Organisations: Literature Review


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PART ONE


What we did

1.14 The aim o this report is to illuminate a range

o developments in organisational learning in central

government. We began by commissioning a literature

review. As the review demonstrates, learning cannothappen within organisations merely through the

implementation o new structures and processes.

Leaders, individuals and teams within organisations need

to adapt their behaviour, devoting more time to learning

beore, during and ater programmes and projects.

Learning needs to become part o routine day to day

working lie.

1.15 We examined 11 case studies where public bodies

have sought to build learning into their core business.

These are set out in Part Two. The lessons in each o these

case studies should be transerable to other organisations.

1.16 To understand the degree to which learning is

prioritised by departments, and what they are doing to

capture and apply learning, we also undertook a survey

o all the main departments. The survey also served to

gain insight into how departments view the guidance and

support provided to them by the centre o government.

In the course o investigating the case studies, and

in examining the role o the centre o government,

we interviewed senior oicials in government with

responsibility or improving learning. Towards the end

o the study, we brought together some o those we hadinterviewed to discuss our indings and what departments

need to do to be more eective at learning. The indings

rom our survey, and rom the interviews we conducted,

are set out in Part Three.

1.17 We have drawn together the lessons rom

undertaking this study into a sel-assessment ramework

(Appendix Two), which provides a basis upon which

management boards can develop ways orward or

building learning into their organisations.


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PART TWO


2.1 Part One showed that organisations learn in

many dierent ways. Learning is not something done

separately rom everyday activity, nor can greater learning

be achieved by simply introducing more systems and

processes. To help understand how departments learn,

we separated learning into our elements leadership,

people, inrastructure and process all o which need to

be in place or an eective learning culture to take root.

The 11 case studies that ollow illustrate dierent ways

in which organisations in the public sector are building

learning into everyday operations.

Leadership

2.2 Leadership means sponsoring and being accountable

or activities which lead to lesson-learning. Leaders canset an example through their own behaviours, by making

time available or review beore and at the end o projects,

and arranging or senior management consideration

o lessons learned. The ePassport programme oers an

example showing leadership at project and programme

level (Case A). A consistent message rom our interviews

and case studies is the need or behavioural change to be

demonstrated at the top o departments. In the case o the

United States Center or Court Innovation (Case H) senior

managers ocused on mistakes and ailure, which can

be uncomortable.

Case Examples inorganisational learning

leaeshp

Case A: Learning from expertise in programme and projectmanagement frameworks: the Identit and Passport SericesePassport programme. Page 17

Case H: Leaders taking the lead in encoraging learningthrogh an open discssion on project failre in the unitedStates Criminal Jstice Sstem. Page 32

Peope

Case B: Shaping learning tools to the needs of staff: The NHSInstitte for Innoation and Improement Releasing Time toCare: The Prodctie Ward programme. Page 19

Case F: Spporting learning across Goernment: TheCapabilit Bilding Programme, Cabinet Office: Deelopingpeople, Soling Problems. Page 28

Case G: Learning from the frontline: HM Reene & CstomsAngels and Dragons initiatie. Page 30

infastte

Case E: Captring the knowledge within the delierchain to inform strateg: The Department for InternationalDeelopment. Page 26

Case J: Spporting learning across local goernment: theBeacon Scheme Improement and Deelopment Agenc.Page 34

Poess

Case C: Maximising the learning from ealation: Theresponse to the 2001 Foot and Moth otbreak. Page 21

Case D: Learning from complaints in health and social care,the Department for Work and Pensions, IPCC and HMRC.Page 23

Case I: Learning from the centre: Gatewa reiews. Page 33

Case K: The role of Parliamentar scrtin in helping centralgoernment learn. Page 36


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PART TWO


People

2.3 The direct experience o rontline sta in their day

to day work means they hold important knowledge about

what works, and where barriers and risks to delivery lie.7

Identiying how to tap into this knowledge eectively ischallenging, with sta suggestion schemes oten ailing

to generate ideas and innovations that can be put into

practice, or else being neglected.8 The Angels and

Dragons initiative at HMRC (Case G), oers an approach

where ideas are tested by a senior level board, and i

successul are seen through by those suggesting the

idea themselves. Sta are supported through the whole

process, rom designing a business case to presenting

the proposal to the board, and coached through the

implementation process.

2.4 Another barrier to learning in organisations is thelack o time sta have or lesson learning. The NHS

Productive Ward Programme (Case B), which aims to

increase the amount o time ront line sta spend in

direct contact with patients, is designed so that ward sta

are able to shape and ollow training modules in ways

that match their needs and priorities. For ward sta to

contribute to the design o the changes to their wards,

and or the initiative to be eective, they need the time

necessary to work through the modules and guidance

provided by the NHS Institute or Innovation.

2.5 Learning rom others also means learning romexternal expertise and consultancy. One o the main

indings rom our report on the Governments use o

consultants9 was that departments were not regularly

planning or, and carrying out, the transer o skills rom

consultants to internal sta to build capabilities. In the

case o the ePassport programme mentioned above

(Case A), however, the programme wrote into all contracts

a commitment to knowledge transer rom consultants,

and the technical, programme and project management

expertise gained as a result is now being employed in the

generation o the new passport.

Inrastructure

2.6 Departments need ways o supporting learning,

such as inormation management systems and ways o

sharing knowledge, particularly where organisations are

geographically dispersed. Online systems, such as that

used by DFID (Case E) provide useul platorms or the

sharing o knowledge and learning, but they tend to work

best when combined with a commitment to bring people

together. The 2007 evaluation o the Beacon Scheme

(Case J) ound that internet and other broadcast methods

or sharing knowledge work best when combined with

personal site visits. Good coordination is also required or

such personal interaction to take place and be eective.

Process

2.7 Processes are also important or learning.

The evidence o our work suggests that departments

should ocus less on the introduction o new processes

or learning, and more on rigorously applying at the right

times those that already exist.

2.8 More eective organisational learning means not

repeating past mistakes. Evaluations are an importantway to learn rom past experience, although the learning

is oten not embedded into organisational culture and

working practice. Maximising the impact o evaluation

requires investment in communicating the indings and

recommendations to a wider audience, in a way that

is relevant to how people work. The Foot and Mouth

outbreak, and the learning derived rom the subsequent

reviews, illustrate how evaluation can be eectively

integrated into departmental and wider practice across

government (Case C).

2.9 While much learning can come rom majorevents and crises, which are oten subjected to detailed

examination, on a day to day basis there is much that

can be gained rom taking time to relect on reasons

or success or ailure, especially when the insights are

derived rom outside the organisation. One key source o

learning is rom users o services. Feedback rom positive

experiences is valuable, but much can also be gained

rom careul analysis o the lessons rom complaints

(Case D). More ormal and systematic external scrutiny

can also be invaluable. The development o the Gateway

process (Case I) has provided a systematic mechanism

or capturing and sharing knowledge about what workswell in project and programme management. Over 2,500

reviews have been completed to date, and there is scope

to learn more rom the post-implementation period and

beneit realisation through greater use o Gate 5 reviews.

Learning also arises rom external scrutiny (Case K),

through the ability o independent reviewers to undertake

objective enquiries.

7 See, or example, Delivering Efficiently: Strengthening the links in public service delivery chains, Report by the Comptroller and Auditor General, HC 940Session 2005-2006.

8 See, or example,Achieving innovation in central government organisations, Report by the Comptroller and Auditor General, HC 1447 Session 2005-06.9 Central governments use of consultants, Report by the Comptroller and Auditor General, HC 128 Session 2006-07.


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CASE A

1 ePassports were introduced in 2006 to improve

security, meet international standards and comply with

the US Visa Waiver conditions. The programme was

demanding and technically complex, and at the same

time as introducing it, the Identity and Passport Service

had to maintain normal operations and keep to existing

service level agreements. The programme ran to very

tight timescales determined, in part, by the United

States (US) Visa Waiver deadline o 26 October 2006.

These challenges meant that learning beore and during

the programme was an imperative or successul delivery.

The Identity and Passport Service was also determined not

to repeat the crisis o the summer o 1999, where the roll

out o a new processing system was one o the reasons or

a loss o public conidence in the UK Passport Agency.10

2 The programme commenced in 2003, with a small

initiation team and project manager, and concluded in

2006-07. There were several major work streams covering

procurement and technical delivery (including systems

upgrades), testing, regional production and business

change. Overall project costs were 13.5 million and the

contract costs 33.6 million (all excluding VAT).

3 In 1999, the Comptroller and Auditor General

reported on that years problems, identiying weaknesses

in the UK Passport Agencys management o the newpassport processing system, in particular, the management

o risks. In response to these lessons, an experienced

risk and issue management specialist was employed

throughout the delivery o the ePassport programme.

The Senior Responsible Oicer treated the management o

risk and contingency planning as a key learning activity

and reinorced it by insisting that consideration o risks

and contingency planning was positioned at the start o all

status and project meetings, rather than at the end.

4 The ePassport Programme management team

was drawn rom a mixture o private and public sector

backgrounds, and a commitment to knowledge transer

was written into all contracts. This sharing brought

a wealth o experience to the team, helping them to

learn quickly rom existing tools in Programme and

Project Management.

5 The broad experience o the programme team helped

to assess eectively the likelihood and potential impact o

risks, and to develop a course o action consolidated into

a regularly reviewed contingency plan. The private sector

experience within the team was also utilised to manage

contractual relationships with third parties, supporting the

Service in its role as an intelligent client.

6 The ePassport team was in regular contact with

an international network o organisations in ive other

nations rolling out similar programmes (including Australia

and New Zealand). Networking took the orm o ace

to ace meetings, bringing together a mix o people

with operational and technological expertise to discuss

standards and the challenges the various teams were

acing. This network was eective in providing an open

and regular exchange o ideas and experience, and gave

the opportunity to benchmark perormance and share

good practice.

7 ePassports were delivered to plan and budget and

have been successully transerred into normal business

operation. The programme closed in November 2006.

Subsequently, it was conirmed by the USA that the UK

membership o the VISA Waiver Programme had been

retained and, to date, 12 million ePassports have been

produced with customer satisaction levels and service

levels maintained. In 2007, the Committee o Public

Accounts commended the programme as an example o

successul project management and procurement.11

Learning rom expertise in programme and projectmanagement rameworks: the Identity and PassportServices ePassport programme

10 The United Kingdom Passport Agency: the passport delays of Summer 1999, Report by the Comptroller and Auditor General, HC 812, Session 1998-99.11 Identity and Passport Service: Introduction of ePassports, Report by the Committee o Public Accounts, 49th Report, Session 2006-07.


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PART TWO


8 Project expertise and standards are available rom

the programme or the development o the next generation

passport. The successul team has largely remained

together, with new people phased into the team in a

controlled way. Nurturing and maintaining successul

teams is a good way to not only act as an exemplaror the rest o the organisation, but also to increase the

organisations ability to deliver change eectively and

repeatedly. Building on the good practice deployed on the

ePassport programme, an internal Management Reerence

Guide has been produced to ensure eective management

control o the National Identity Scheme (NIS). There is an

expectation that this is used by managers as a checklist

beore, during and ater all projects and programmes.

9 The Identity and Passport Service also publishes a

set o annual reports on the implementation o its main

projects and programmes. Compiled by sta rom theServices Standards and Practices team, they are placed

on the Services website. Each report sets out the project

objectives, and identiies what has been delivered and the

lessons learnt, both in terms o good practice and areas

or improvement. Senior Responsible Oicers are held

accountable by the Executive Committee or implementing

the lessons published in their reports.

10 There is scope or wider dissemination o the lessons

learnt but despite recommendations by the Committee o

Public Accounts on the sharing o good practice rom the

delivery o this programme, and winning a Civil ServiceAward or programme delivery, there has been little

interest rom other departments in learning rom the team.

Key Lessons

n Programme and Project toolkits (such as Prince 2)

already exist to relect on perormance and capture

learning. Those leading projects need to be ully

committed to the application o such tools.

n Lessons learnt documents work best when they

include a candid assessment o perormance.

n Setting expectations or management teams to

incorporate lessons learnt into their planning and

delivery helps address the risk o knowledge being

acquired and shared, but not then applied.


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CASE BThe NHS Institute or Innovation andImprovement Releasing Time to Care:The Productive Ward programme

1 The Productive Ward programme seeks to address

the variation o patient experience in hospital wards across

the NHS by helping nurse leaders and their ward teams

to identiy ways o releasing more o their time or direct

patient care. The NHS spends around 25 billion a year

on acute health services. This accounts or 41 per cent o

the NHS budget and two thirds o this (around 17 billion)

is spent on ward-based care. The ward is the basic work

unit o the entire hospital system, and is where quality and

saety or patients really matters.

2 The NHS Institute or Innovation and Improvement

(the Institute) estimates that ward-based nurses typically

spend only 25-35 per cent o their time on direct patient

care. The rest is spent on activities such as dealing withhandovers with other sta, hunting and gathering

or equipment, and on paperwork and administration.

Nearly a quarter o nursing time is spent moving between

tasks and patients. The Productive Ward programme is

designed to enable nurses to lead change or themselves

and identiy improvements that will lead to well organised

wards, resulting in more time being released or direct

patient care.

3 The Productive Ward consists o a set o modules

written in clear language that provide sel directed

learning opportunities or rontline sta. Furtherinormation, guidance and training can be provided by the

Institute to help sta build competence and conidence

to lead sustainable improvements in their wards. The key

principles behind the programme are that:

n ront-line sta are the experts in their wards;

n sta should have accurate and timely measures so

that they can measure progress;

n the Board and support systems in the hospital

should be aligned to support the ward in providing

excellent care;

n the learning modules are underpinned by LEAN

principles which encourage standardisation in

ward processes to increase reliability and saety.

As a result, wasteul activities, such as duplication

and over-stocking, are driven out to help to

release more direct time or care and improve the

patient experience.

4 In developing the programme, the Institute drew

on the learning acquired rom a number o pilot sites in

each o the 10 strategic health authorities. Key strategic

partnerships were established with organisations such

as the Royal College o Nursing because o the need

to communicate in appropriate ways to the dierent

sets o proessionals and leaders to gain commitmentat both chie executive and ward level. Experience

had shown, or example, that chie executives engage

more readily when guidance is ocused on outcomes

and eiciencies that align with existing priorities, while

nurses are more responsive to messages around gaining

more time or improving patient care, as well as reducing

administrative duties.

5 In developing the content and approaches in

the training materials and supporting guidance, the

programme has been developed in close partnership with

learning partners in each Strategic Health Authority, andwhole hospital roll-outs are well underway in Nottingham

and Central Manchester. The Institute has worked

extensively with the ward teams to reine the training

modules and guidance so that the inalised programme,

launched in January 2008, relects the wealth o learning

and experiences gathered rom the dierent hospitals.


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PART TWO


6 Giving wards the reedom to interpret and adapt

the Productive Ward modules has been a key actor

in their successul application. The modules ocus on

giving each ward a systematic way to analyse how they

currently operate, and a ramework to identiy possible

process solutions or sustained change. Although theInstitute oers support in the development o solutions

based on wider experiences, advice is oered in the orm

o options, rather than a prescriptive instruction.

7 The Institute recognises that dierent Trusts require

dierent levels o support to get the most out o the

programme. As a result, there are three options or

implementation, dependent on the local context and

experience o organisational change within dierent trusts.

These are:

n NHS organisations in England can requestthe modules or sel-directed learning and

implementation. They receive printed and online

materials to work through.

n The standard membership oer or Trusts in

England with some experience and capacity in

leading improvement or organisational change.

Trusts receive training or three sta in how to

implement the 15 modules, which is delivered at

our 1-day workshops. The training has a learning

by doing approach to build capability in the

organisation and their sta. Access is also given to a

weekly online clinic, during which Trusts can gainexpert implementation support live over the internet.

n The accelerated membership oer is aimed at

Trusts with limited experience in organisational

change, and in need o greater knowledge and

skill transer. In addition to the standard oer this

option includes training in module implementation

or 10 sta instead o three, executive coaching to

help senior trust leaders scope the work, mobilise

the right resources and set up project management

arrangements, and three days o on-the-ground

support rom an expert clinical acilitator (usuallya nurse).

8 Although still at an early stage (a ull national

evaluation is currently being undertaken) the Productive

Ward has generated encouraging results and there is

growing domestic and international interest in it. The NHS

Institute has identiied improvements to wards across the

NHS as a result o the Productive Ward. Examples romearly use include:

n the time taken to dispense drugs to inpatients

has reduced by more than hal, whilst saety has

increased (allowing re-investment o time into

saer care);

n patient handover time has reduced by one-third, and

quality has increased;

n meal wastage rate is down rom 7 per cent to

1 per cent (10,000 o unnecessary annual meal

requests identiied in one ward);n there has been a reduction in patient complaints and

greater levels o sta satisaction through calmer and

more organised wards; and

n the initiative has led to a decrease in unplanned

sickness and absence amongst ward sta where the

Productive Ward has been implemented.

9 Further inormation on the learning derived to date

rom the programme can be accessed online at the NHS

Institute or Innovation website.12

Key lessons

n The Productive Ward programme provides a

ramework and tools, which have enabled nursing

teams to examine what they do on a day to day

basis rom a dierent perspective. These tools have

greatest impact where there is a genuine demand or

them rom ront line teams, rather than where they

are mandated by management.

n Open communication around the time wards

need to apply the initiative is key to building trust

with users.

n Learning toolkits need to be developed with, rather

than simply or, users. It is important that tools

strike the right balance between oering suicient

direction and allowing room or local interpretation

and ownership. They thus require signiicant testing

with users.

12 http://www.institute.nhs.uk/quality_and_value/productivity_series/productive_ward_%3a_video_documentaries. html.


23/59


CASE C

Maximising the learning rom evaluation:The response to the 2001 Foot and Mouth outbreak

1 In 2001, the UK suered its worst outbreak o Foot

and Mouth disease. Dr Iain Andersons independent

inquiry and a report by the Comptroller and Auditor

General, as well as reports by the Committee o Public

Accounts and the House o Commons Environment Food

and Rural Aairs select committee that ollowed, ound

that the contingency plans and procedures invoked at the

time were inadequate or handling a crisis o the scale o

the 2001 outbreak.13

2 Dr Andersons inquiry, published in 2002,

identiied the main lessons to be learned and included a

comprehensive set o recommendations to government

and other organisations with a role to play in preventing

and controlling any uture outbreaks. In 2007, a urtheroutbreak occurred and Dr Anderson was again asked to

review the response and identiy any lessons that needed

to be learnt. The 2007 inquiry concluded that the overall

response in handling the outbreak had been good.

Perormance, taken as a whole, was much improved when

compared to 2001, particularly contingency planning.

Many o the lessons identiied in 2002 had been acted

upon, although there was still scope to develop the

inormation systems o the Department or Environment,

Food and Rural Aairs (Dera).

3 Clearly communicating the purpose o lessonreviews (such as improving contingency planning) was

an important oundation in building good working

relationships between the inquiry team and the dierent

individuals and organisations aected by the 2001 and

2007 Foot and Mouth outbreak. A commitment was

made to communicate to all involved, and not just

the Department.

4 The recommendations made in Andersons 2001

report, and in the Comptroller and Auditor Generals

report, encouraged a lessons learned culture within

Dera and its agency Animal Health. Lessons reviews

are now conducted or any exotic disease incident.

For each recommendation, an owner is assigned who is

accountable or its implementation. Ongoing scrutiny

into whether the 2001 recommendations had been

implemented was provided by regular updates requested

by the Committee o Public Accounts. In its Ninth Report

2005-06, the Committee o Public Accounts included

an update on whether lessons had been applied. It

concluded that good progress had been made on

most recommendations.

5 The recommendations rom the 2002 review are

relevant to Deras work on all orms o contingency

planning, not just Foot and Mouth. Since the 2001

outbreak, the Dera team responsible or contingency

planning has reviewed and revised the Emergency

Planning guide that provides generic advice on planning

and response. This activity is reinorced through regular

Dera planning events. The January 2009 event gave a

greater ocus on learning rom exchange o experience.

The Emergency Planning guide is updated on an annual

basis, building in ongoing lessons learned across the

department rom the handling o various animal diseaseoutbreaks or crises such as looding. The Exotic Disease

Response Framework plan is also updated annually. It can

be viewed at: http://deraweb/animalh/diseases/control/

contingency/index.htm.

13 Dr Iain Anderson, Foot and Mouth Disease: Lessons to be Learned Inquiry Report, HC 888 2002.The 2001 Outbreak of Foot and Mouth Disease. Report by the Comptroller and Auditor General HC 939, Session 2001-02.The 2001 Outbreak of Foot and Mouth Disease. Report by the Committee o Public Accounts 5th Report, Session 2002-03.The impact of Foot and Mouth Disease. Report by the Environment Food and Rural Aairs Committee. 1st Report, Session 2001-02.


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PART TWO


6 There has also been recognition that although

lessons learnt documents and supporting materials are

useul, the actual experience o handling an emergency

is critical. A system is being ormalised where employees

can support or shadow a team in the midst o handling

an emergency. Members o the Animal Health agencyworked in the emergency operations centre or the lood

response in 2007 so they could pass on relevant lessons

rom their own experiences. To aid speed o response to

policy making on exotic disease incidents, the department

has developed a Policy Response Operations Manual,

which describes roles and responsibilities and provides

web-based access to the supporting materials, movement

licences, legislation and control strategy documents.

This will support handovers and succession planning, and

builds on the Framework operational response guidance.

7 Animal Health reports a shit in the working cultureo the teams responsible or handling disease outbreaks.

Scenario testing has become part o regular working

lie and signiicant national exercises are run on a two

to three year basis, with more regular exercises at local

oice level, to test the eectiveness o contingency plans.

In running these exercises, teams have adopted a number

o the tools and methods introduced by the military

advisers who set up the Joint Coordination Centre to

handle the 2001 crisis. These include hot wash ups and

cold debries, which allow or learning in the thick o

the action, as well as urther relection once the action

is over.

8 The team assembled or the 2007 Anderson review

contained individuals who had been involved in 2001.

This continuity proved advantageous. It enabled the

review team to get to the key issues quickly and led to

a ully inormed analysis o whether the improvements

recommended in 2002 had been made. From Deras

perspective, the consistency in the inquiry teams led to a

more ocused, tighter evaluation than might have been

the case with a new team in place.

9 The results o the handling o the Foot and Mouthdisease outbreak in 2001 resulted in wide recognition that

a thorough review o plans and processes was necessary.

In 2007, initial signals suggested the outbreak had been

handled competently. Under such circumstances, the

review team ound it harder to get the candid responses

they required rom Dera to some o their key questions.

This reticence was mitigated by reinorcing the approach

that the review was about lessons learned, rather than

the basis or a blame game.

10 The Cabinet Oices Civil Contingency Secretariat,

established in 2001, is responsible or emergency

planning in the UK. Its Concept o Operations builds on

some o the recommendations in the Foot and Mouth

reviews, and relects the close relationships it has sought

to develop with teams across government working oncontingency planning.

Key lessons

n More constructive relationships develop i the

evaluation or review team clearly communicates

its purpose rom the outset. In the case o the

2002 inquiry, the assembled team recognised the

importance o maintaining a ocus on identiying

lessons learnt and driving improvement.

n Continuity in the make up o inquiry/evaluationteams can enhance their eectiveness by capitalising

on existing insight into key issues, understanding o

the wider system in which they exist, and building

relationships with the key stakeholders involved.

n Maximum value rom an evaluation/inquiry can

be achieved through sharing key indings and

recommendations with a broader audience, as

they oten have a wider relevance. Sharing these

indings and recommendations can lead to a more

collaborative response.


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CASE D

Learning rom complaints

1 Providing appropriate systems and processes

through which the public can complain about services is

necessary, not only to right individual wrongs, but also to

identiy areas that need to be strengthened and improved

more generally.

Looking across Government

2 The Parliamentary and Health Service Ombudsman

undertakes independent investigations into complaints

that government departments, a range o other public

bodies in the UK, and the NHS in England have not acted

properly or airly, or have provided a poor service.

3 Each year, in an annual report, the Ombudsmanprovides an account o the key lessons to be learnt rom

complaints, and how they have been handled that year.

In 2008, the Ombudsman published new Principles

of Good Complaint Handling (see box below), which

draws on the experience and expertise o her Oice.

They provide an objective ramework within which public

authorities should seek to work. The Ombudsman also

publishes special reports in particular areas such as the

handling o complaints about continuing care unding.

Complaints in this area have decreased as part o the

Ombudsmans workload (rom 58 per cent in 2005-06 to

31 per cent in 2006-07).14

4 In recent years, the Comptroller and Auditor General

has published three value or money reports on how the

Government learns rom complaints. In 2005, a report

covered redress across government.15 The report ound

that in 2003-04, within central government, there were

1.4 million new cases, with over 9,300 sta working on

dealing with complaints at a total cost o 510 million.

5 The report ound that the public were oten conused

about how to complain, and identiied a wide variation

across dierent departments in how complaints are

deined, managed and acted upon. Most relevant to this

report were the problems with inormation management,

with around hal o central government organisations not

able to answer how many complaints they had received in

two years beore the report. To improve the learning rom

complaints, the report recommended that departments

collect inormation on complaints and on appeals in a

regular and systematic way.

Learning rom customer complaints

at HMRC6 The Ombudsmans 2007 report, Tax Credits; Getting

it Wrong, addresses the issues surrounding the tax credit

system and the progress HMRC has made since a previous

Ombudsmans report.

14 Feeding back? Learning from complaints handling in Health and Social Care, Report by the Comptroller and Auditor General HC 853, Session 2007-08 (seeparagraph 2.50 o the report).

15 Citizen Redress: What citizens can do if things go wrong with public services, Report by the Comptroller and Auditor General, HC 21, Session 2004-2005.

Pnpes of goo compants Hann (Paamenta anHeath Seve Ombsman). goo ompant hann means:

1 Getting it right

2 Being cstomer focsed

3 Being open and accontable

4 Acting fairl and proportionatel

5 Ptting things right

6 Seeking continos improement


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PART TWO


7 Since 2005, HMRC had considered the

recommendations made by the Ombudsman and

had improved the tax credit system, with enhanced

inormation provided to customers in terms both o its

clarity and helpulness, and a reduction in the backlog

o disputed overpayment cases due to a successulstreamlining procedure. The number o overpayments

being remitted had allen and overall there were

ewer complaints regarding poor advice, inadequate

helpline access, underpayments and ailure to reply.

The Ombudsman has seen a all in the number o

complaints reerred to the oice by 18 per cent.16

The report concluded that while there is still more to be

done, improvements had been eective, successul and

promising or the uture.

Learning rom customer complaints atthe Department or Work and Pensions

8 Jobcentre Plus, The Pension Service and the

Disability and Carers Service received 70,000 recorded

complaints in 2007-08.17 For those customers who do

complain, the complaints system was ound to be easily

accessible, with the majority o complaints handled

directly by ront-line sta.

9 Over 40 per cent o complainants remained

dissatisied, however, or a number o reasons relating

both to the complaints process and to the outcome o theircomplaint. The Department introduced an Independent

Case Examiner to report on how it handles complaints.

In addition, the Department introduced a process to

inorm its agencies o the systemic issues observed

through the examination o individual complaints cases.

The agencies also have processes in place or sharing

lessons with local oices.

10 The report did however ind a lack o quality

assurance standards and dierent typologies o complaints

at agency level, making it hard to make comparisons

o emerging problems. The report concluded that thepotential to learn lessons rom complaints is not ully

realised because o a lack o a department wide system to

record consistent and timely inormation on complaints.

Learning rom complaints handling inhealth and social care

11 In October 2008, the Comptroller and Auditor

General reported on complaints handling in health and

social care.18 In this case, the complaints systems werealso ound not to be straightorward (particularly or health

service users) and the handling o complaints was taking

too long. As a result, many o those who were dissatisied

with the service they had received do not go on to make

a complaint, thus reducing the ability or the NHS and

social care organisations to learn rom complaints.

Only ive per cent o those dissatisied with the NHS and

32 per cent with social care made a complaint.

12 Overall, the report ound a lack o systematic

learning rom complaints to improve NHS and social care

services, with an absence o any ormal means to capturekey learning points rom complaints. In social care,

there is a well developed support network the National

Complaints Managers Group which provides a way or

sharing learning, and the Department o Health has a

network, the Voices or Improvement Network to oster

closer working relationships across health and social

care. However, both arrangements lack methods or

capturing learning.

13 In 2006, the Department o Health announced its

intention to reorm the health and social care complaints

arrangements. The White Paper Our health, our care,our say sets out the Departments commitment to make

it easier or people to complain about their experiences

o using health and social care services, improve the

quality o responses received, and improve services

as a result. This proposal is an important part o the

Governments intention to bring the planning and

management o health and social care services more

closely together. In April 2009, the Department plans

to introduce a new comprehensive, single complaints

system across health and social care, which ocuses on

resolving complaints locally, with a more personal and

comprehensive approach to handling complaints, and

greater commitment to learn rom mistakes made.

16 Tax Credits: Getting it Wrong, Parliamentary and Health Service Ombudsman, 5th Report, Session 2006-07, Appendix A.17 Department for Work and Pensions: Handling Customer Complaints, Report by the Comptroller and Auditor General, HC 995 Session 2007-08.18 Feeding back? Learning from complaints handling in Health and Social Care, Report by the Comptroller and Auditor General HC 853 Session 2007-08.


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PART TWO


Learning rom complaintsat the Independent PoliceComplaints Commission

14 In 2008, the Comptroller and Auditor General

published a report on the Independent Police Complaints

Commission.19 The report ound that there is good sharing

o knowledge with the police through the distribution o

a series oLearning the Lessons bulletins. These bulletins

outline the process ailings and best practice uncovered

by IPCC investigations. The reactions o the members o

police orces who were interviewed, were avourable and

they regarded the IPCCs work as a positive step in helping

the police to improve perormance. To urther improve

learning rom complaints the report recommended that

caseworkers receive accredited training and that the IPCC

should undertake regular satisaction surveys and externalreviews o these cases to help identiy any weaknesses in

their system.

Key lessons

n Learning rom complaints works best when

there are systems to capture and analyse what

people are complaining about in a consistent and

rigorous manner.

n I complaints systems are complicated, or i people

do not eel their complaint will make dierence they

are likely not to complain. This means a key source

o knowledge or an organisation is lost.

n Regular reviews o complaints handling to identiy

any weaknesses in the operating processes are

important. Customer satisaction surveys and

external reviews o cases are suitable ways o

obtaining the material or these reviews.

19 The Independent Police Complaints Commission, Report by the Comptroller and Auditor General, HC 1035, Session 2007-08.


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CASE ECapturing the knowledge within the deliverychain to inorm strategy: The Department orInternational Development

1 Despite progress internationally in tackling the

AIDS epidemic, including lower HIV prevalence in some

countries, more access to HIV treatment and greaterresources available, the epidemic continues to grow.

Prevention programmes are only available to one in ive

people who need them, and or every two new people on

treatment, another ive are newly inected.20

2 The Department or International Development

(DFID) leads the United Kingdoms contribution to

the global response to the AIDS epidemic. It does so

through own country programmes, through unding o

multilateral development institutions, and through support

o relevant research programmes. In 2004, ollowing a

report by the Comptroller and Auditor General on theDepartments response to HIV and AIDS, the Committee

o Public Accounts reported that the Departments overall

strategy was unclear. The Committee concluded that the

eectiveness o its programmes would depend on knowing

what works in tackling the epidemic and why, and on

communicating this knowledge globally.

3 In June 2008, the Department published a strategy,

Achieving Universal Access which sets out the UKs

response to these challenges. The strategy is based

on a detailed evaluation o the implementation o the

previous strategy. The new strategy takes into accounteedback and learning rom a consultation undertaken in

mid-2007, coordinated on the Departments behal by the

UK Consortium on AIDS and International Development

(a group o UK based charitable organisations working

in the HIV and AIDS arenas). The consultation

produced more than 90 submissions rom domestic

and international NGOs, the private sector, academic

institutions, and multilateral agencies.

4 The UK Consortium on AIDS and International

Development held a series o online discussions on the

AIDSPortal, an international initiative providing toolsto support global collaboration and knowledge sharing

among those responding to the AIDS epidemic. The

discussions ran in parallel with the main consultation

process and oered the opportunity to ocus in more detail

on speciic issues drawn rom consultation questions.

5 In 2007, the Department held its Human

Development Retreat (a network o individuals working in

Health and education rom across DFID and its regional

oices), with the aims o capturing an understanding

o what works in tackling HIV and AIDS in developing

countries, and helping to ind solutions to the barriersand challenges. The event was structured around the

central question; What should the UK do to change the

course o the AIDS epidemic? The Department drew

on a technique called Open Space, which provides a

means o organising a workshop that includes multiple

organisations, with dierent perspectives and agendas.

6 An interim evaluation o the earlier Taking Action

strategy was included in the design o the new strategy.

It was important that the results o this evaluation were

in place at the outset o revising the strategy. One o the

key lessons was the need to set targets against whichDFID could measure their perormance, and to which the

Department would be held accountable. Specialists who

conducted the evaluation o Taking Action were directly

involved in the development o the measures or the

updated strategy.

20 Achieving Universal Access, DFID, 2008. www.did.gov.uk/Pubs/iles/achieving-universal-access.pd.


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PART TWO


7 The Department has introduced an enhanced

intranet acility to better capture the knowledge o

sta working in developing countries. The AIDS &

Reproductive Health Inormation System (ARHIS) has

improved DFID sta access to AIDS and reproductive

health inormation, and started to build an evidencebase o best practice and lessons to support p

helping govt learn

Documents