Hello everybody, welcome to the latest Lean FSL blog. The Christmas break already seems a long time ago, and thoughts have undoubtedly turned to how to escape the dark and cold British winter!
Another, almost perennial, occurrence during the long winter months is the news headlines regarding the latest crisis in the NHS. Yet again, a few weeks ago, we saw the media reporting that A&E departments were being over-whelmed with high demand. I – probably along with many of you – am left frustrated by a complete lack of ‘joined-up’ thinking around healthcare from our politicians, and the lack of courage to have a proper debate about the ‘perfect storm’ that the NHS is in the middle of right now. They seem more interested in scoring cheap political points, than really looking for some ‘root cause’ around healthcare improvements that can be built into a viable future state.
All of the headlines and debate made me wonder what has happened in the NHS since a book I read (back in about 2010), called ‘Making Hospitals Work’, written by Marc Baker & Ian Taylor (see the link at the end of the article). The book tells a story about a Chief Executive and his team at a fictional (although based on a number of actual examples) NHS Acute hospital, who set about through Value Stream mapping and the application of lean thinking (takt time, bottleneck optimisation, pull systems, Practical Problem-solving etc.) dramatically improving the flow and reducing the time patients spent in hospital. At the time it seemed to be a step-change; a revelation that Healthcare managers up and down the country would willingly embrace. But, what’s happened since?
Have the ‘naysayers’ who oppose lean in healthcare won the day, because patients are not to be treated like tins of beans? (As if anybody trying to bring lean thinking to bear in this environment ever suggested otherwise!). Or maybe it’s just a case of bad timing; budget cuts have been applied in one area of the Value Stream (namely Social Care, which hasn’t had the same level of protection as core NHS services), and this has created a new bottleneck, which unsurprisingly has caused the whole system to grind to a halt?
Baker & Taylor described very elegantly two different ‘demand’ loops affecting Acute Hospitals. Firstly ‘Demand to Access’ – that is the inflow of patients from homes, GPs, NHS phone-lines etc. And secondly, ‘Demand to Get Out’. The two are interconnected in some ways, but exclusive in others. What appears vital is to understand what the ‘takt time’ is for each loop, and to ensure that there is sufficient capacity to meet this demand in each part of the loop. Not any easy sell! I can remember discussing this with senior clinicians in A&E a few years ago, who realised that they needed more senior people on nights and weekends to enable better decision making and reduce admissions and workload for everybody else, but couldn’t get people to apply for these out-of-hours roles!! Unless we do something different over the next few years, this ‘takt time’ is only going to reduce (i.e. Get more challenging!). Stopping people even needing to get to the front door of A&E is surely a key objective over the next few years, as is ensuring that capacity is configured to meet demand more effectively.
The whole patient journey lends itself well to a Value Stream approach in my view. The acute hospital is only one step in the journey for most patients, and what happens before and after the treatment in hospital forms part of the effectiveness of the whole system. Likewise, there’s little point protecting the budget of one area of the value stream if you cut capacity elsewhere, the systems overall capacity will reduce to that of the new bottleneck (or even slightly lower), and throughput across the whole system will be reduced.
So, does lean still have a place in the NHS, or has the small progress it was making a few years ago been crushed by the sheer size of the challenge and the impending crisis? Where are the success stories? Where indeed are the lean experts? I live near Stafford, I haven’t seen or heard of any of the big-hitters in the lean world offering their support to turn our local trust around (it used to be called Mid Staffs, in case you’ve just landed from Mars!). Imagine the kudos of saying that they’d proven their approach worked, and that they did it for nominal cost too, to prove the principle to both public and politicians! Imagine then, the ability to shape the political debate, to move it on to the ground of both better quality and increased capacity being free, when you eliminate waste and improve flow! Not an argument over who is, and who isn’t, going to chuck the most borrowed money at the problem.
I’m a realist, lean isn’t a panacea for all of the troubles and challenges facing the NHS, but we seem to have massively failed to deliver on its potential. Politicians – and I assume the electorate – view the NHS as a sacred cow. But with an ageing population and ever increasing expectations as to what is to be provided by the NHS, how else are we ever going to ‘Make Hospitals Work’?
I’d love to hear your thoughts and experiences of lean implementation in the NHS and hospitals in other countries.
Look after yourselves, and ‘stay lean’!
Graham
Link to ‘Making Hospitals Work’ by Baker & Taylor:
http://www.leanuk.org/shop/all/making-hospitals-work