An evening visit to casualty was an eye-opener for Dr Dilys Jones, who feels it is time for managers to start listening to their frontline staff

Sitting with a close relative in a busy inner-city accident and emergency department at 11pm was a salutary lesson in how the NHS might be improved. The department was small, cramped, tatty and quite dirty.

There was a drinks machine and a few toys, but no board announcing waiting times. Because of the lack of space, the toys overflowed into the vestibule of the patients' toilets.

Staff were providing a good clinical service under very difficult circumstances. It was crowded, and many of those waiting did not have English as a first language.

Behind a green curtain in the corner, initial triage was being carried out.When the patient concerned did not speak English, the triage nurse spoke more loudly, and more slowly, enunciating every word for the entertainment of the rest of those in the waiting area. There was no interpreter, save some patients' relatives who could speak some English.

This was acted out several times until, after an hour's wait, it was my relative's turn. It was decided, after seeing several health professionals, that he needed an x-ray.

As there was only one porter on duty for A&E, as well as the hospital, we had to wait another hour. I wheeled him to x-ray myself.

While waiting, I talked to the receptionists, nurses, nursing assistants and a domestic, who were all extremely unhappy about the environment, lack of staff and the long waits patients had to endure due to the lack of beds.

They were highly motivated and wanted things to change for the better. They had many ideas about how to solve the problems - such as piloting a telephone interpreter service, helping the porter out when they could for certain tasks, and asking fit people to wheel their relatives to x-ray when it was appropriate.

One nurse said he had spent a lot of time thinking about the practical ways that ideas could be tested or put into practice. But staff felt they were not encouraged to have these ideas and that there was no opportunity to talk things through with people running the hospital, or with each other. 'We are all too busy to have the time.'

They were frozen into inactivity on this front by the lack of opportunity to use their ideas for solving problems.

This raises questions. People need to feel they can contribute meaningfully to improving services, and to help develop safe and secure environments over which they have some control.How can good ideas be turned into reality at a local level? How can time and space be found for harvesting the vast potential for problemsolving that professionals have?

Traditional approaches to problem-solving and project management are very top-down.

There needs to be room for bottom-up, too, to identify those who can bring a fuller understanding, and solutions, to complex service delivery issues.

Many of the building blocks were in the department that evening.

Staff still maintained enthusiasm and motivation, and managed to provide a service despite the challenges. But there was no process to bring them together and to make tangible improvements.

Helping professionals to do this means acknowledging that their ideas are important; it means helping them to develop concepts and skills to recognise opportunities and ensuring they have the self-esteem and knowledge to promote the ideas where they might have hesitated in the past.

Recent work with similar groups in the public sector has shown that creating space for professionals to come together in large or small groups for action-oriented problem-solving works well. The most impressive results have been when the time has been firmly focused on a current problem, and when all the relevant players needed 'to make something happen'.

New thinking and possible solutions have come from people who have worked with the problems every day.

Permission by senior managers to continue thinking like this after the meeting is important.

Many approaches do not need permission from several layers of management above, and can help teams develop and innovate.

If professionals at the A&E department had experienced such an approach, it seems likely they would have tried a number of ideas, with consequent benefit for patients.

While these approaches will not, of course, solve all the problems in the NHS, they could engage more systematically the people who can offer most help.

Dr Dilys Jones , former senior medical officer at the Department of Health and consultant psychiatrist at Broadmoor Hospital, is a director of OBTI Consulting.