There’s a moment that happens in every Emergency Department (ED), usually around 3 am on a winter night. The waiting room is full. Ambulances are queued outside. The escalation policy says one thing, but everyone knows we’ll actually do something else entirely. A senior nurse catches your eye across the department and you both know: we’re holding this together with intelligence, experience and workarounds that exist nowhere in any policy document.
Ron Bronson has written a fantastic blog that names what we’re doing here. In his blog post, Design as repair, he argues for a fundamental shift in how we think about systems – away from innovation and optimisation, towards maintenance, care and the people who keep broken things running.
This framework feels uncomfortably accurate in Urgent and Emergency Care (UEC) in the NHS.
What the framework says
The core argument is simple but radical: the most important part of any system is often the person who keeps it from breaking today.
Systems don’t usually fail catastrophically. They leak. They jam. They get stuck. And when that happens, it’s not executives or designers who respond – it’s the people embedded in those systems. The ED nurse who knows which consultant to call for which presentation. The paramedic who understands the real capacity at each receiving hospital. The support worker who coordinates discharge because the formal pathways have broken down.
This is repair work. It’s invisible, undervalued, and absolutely essential.
The framework challenges the dominant logic in healthcare improvement: that what we need is more innovation, better optimisation, breakthrough solutions. Instead, Bronson argues we need to see, support, and design for the repair work that’s already happening.
His key principles include making invisible work visible, designing for slack rather than just efficiency, treating governance as a design problem and valuing consequence over novelty. He draws on James Scott’s concept of legibility – how institutions try to make complex realities simple enough to manage from a distance, and how that reduction always misses the knowledge that actually makes things work.
Why this matters for emergency medicine now
I’ve written previously about self-organised criticality – how EDs naturally evolve towards critical states where one additional patient can trigger system collapse. Bronson’s framework explains what prevents those collapses: it is repair work.
Every time an experienced nurse finds one more trolley, every informal conversation that prevents an admission, every relationship that smooths a transfer – this is the repair work keeping our EDs from tipping into criticality. But we’ve designed a system that neither sees nor supports it.
We’re drowning in innovation whilst repair work goes unsupported. Every week brings another digital initiative, pathway redesign, transformation programme. Meanwhile, the experienced band 6 who knows how to navigate the system when it’s failing is leaving for agency work, taking irreplaceable institutional knowledge with them.
The policy-practice gap is growing. The written escalation policy bears little resemblance to what actually happens at 2 am. The formal referral pathway isn’t how patients actually move through the system. Front-line staff carry this cognitive burden daily; knowing the rules whilst understanding they don’t function in reality.
Coordination work has become invisible. The phone calls that prevent admissions, the conversations that smooth transfers, the relationships that make partnerships work – none of this appears in job plans or gets recognised in appraisals, yet services would collapse without it.
We’re optimising ourselves into fragility. Every efficiency drive removes slack. Every restructure disrupts relationships. Every new system adds coordination costs. We’ve made our departments incredibly efficient at things going to plan, and catastrophically vulnerable when they don’t.
This is the connection: repair work is what keeps us from criticality. But we’ve built a system that treats it as inefficiency rather than essential infrastructure.
Why this is so difficult in the NHS
The barriers aren’t technical. They’re cultural and structural, and Bronson acknowledges them even if he can’t solve them.
Power structures resist redistribution. Frontline staff have extraordinary operational knowledge but minimal decision-making authority. Management have structural access but are often distant from operational reality. Bridging that gap requires redistributing power, which threatens existing hierarchies.
Defensive management culture makes truth-telling risky. When frontline staff describe the gap between policy and practice, it’s often heard as criticism rather than operational intelligence. When workarounds are made visible, the response is frequently “that’s non-compliant” rather than “what does this tell us about our policies?” People stay quiet and protect their workarounds through silence.
The system lacks capacity for reflection. Repair work requires time: to coordinate, to document, to share knowledge. But UEC staff are in constant firefighting mode. Creating space for reflection when people are drowning feels impossible.
Improvement structures get captured. Initiatives like Learning and Improvement Networks (LINs) could theoretically create space for this work. But they risk becoming another layer of performance management: where polished success stories get shared whilst messy truths remain hidden, where the appearance of listening substitutes for actual redistribution of power.
The fundamental tension: the preconditions for implementing this framework are precisely what need changing. You need psychological safety to have honest conversations, but the culture that prevents psychological safety is what needs addressing. It’s a recursive trap.
Where hope lives
Hope lives in recognition. When you read Bronson’s framework and think “this is exactly what I’m experiencing,” that’s not nothing. The gap between policy and practice is real. The invisible coordination work matters. The workarounds represent genuine expertise. Naming this clearly removes the gaslighting that makes frontline work exhausting.
Hope lives in daily repair work itself. Every shift where you keep things running despite impossible conditions is an act of care. Every time you mentor a junior colleague in what actually works, you’re preserving institutional knowledge. Every workaround you protect is keeping patients safer. That’s not system transformation, but it’s the work that keeps people alive.
Hope lives in maintaining clarity. The ability to see what’s actually happening – where systems leak, what repair work is essential, which policies don’t function – is rare and valuable. When circumstances eventually shift, the NHS will need people who maintained accurate understanding through difficult times.
Hope lives in the micro-cultures you can influence. You probably can’t change NHS culture as a whole. But you can create a team culture where workarounds are discussed openly, where coordination work is valued, where people are protected for speaking truth. Those pockets of sanity model what’s possible and demonstrate that different approaches can work.
And crucially: hope lives in refusing to accept that how things are is how they must be. The current model is unsustainable. Something will give – through financial pressure, workforce crisis, political intervention, gradual cultural shift. When that transition comes, it will need people who understand what actually happens, can articulate why the old model failed, and know what repair work looks like.
You’re building those capabilities now through daily practice, through conversations with colleagues who see clearly, through the workarounds you protect and teach, through refusing to gaslight yourself about what you’re experiencing.
That’s not the hope that NHS motivational posters sell. It’s quieter, less spectacular, and more real.
What we can actually do
Protect and teach the repair work. Make sure junior staff learn not just formal procedures but the real protocols. Pass on institutional knowledge. Legitimise the workarounds that keep patients safe.
Build peer networks. Find colleagues across organisational boundaries who see what you see. Those relationships are valuable whether or not formal improvement structures deliver.
Be strategic about participation. When asked to contribute to initiatives, ask: will this create genuine slack? Redistribute actual decision-making power? Or is it performance that extracts more labour? Choose accordingly.
Name reality when safe. “Our policy says X but we actually do Y because Z” is operational intelligence. Find the spaces and people where that can be spoken.
Keep paying attention. Keep noticing what works, what breaks, who holds things together. That diagnostic capacity is what the NHS will need when it finally becomes ready to hear it.
I strongly encourage you to read Bronson’s original piece. His writing doesn’t promise easy answers, but it names something important about how complex systems actually function.
For those of us in UEC, this framework offers clarity if not solutions. And sometimes clarity is the first step towards knowing what’s actually needed. Even if we can’t implement it fully yet, we can start seeing differently.
And seeing clearly is its own form of hope.
Stevan
