Leading improvement in English healthcare: What obstacles are in the way?

Recently, a long-standing colleague and experienced lean practitioner indicated to me that they were no longer trying to work in the English NHS, and were now focussing their efforts, energies and wisdom in healthcare outside of England. I found this both sad and odd. Why would it be ‘better’ for this person to use their considerable talents elsewhere, when we need so much help in the English NHS?

Free image from a Pixabay

When I enquired as to why they had made this decision, it seemed that the perception seemed to be that English healthcare people just don’t seem to want to improve. I wasn’t sure really how I felt about that. My immediate reaction was that that just didn’t seem to be the case for me, perhaps they just didn’t want to improve using lean as their preferred approach? Or maybe I was just being defensive. I wondered what obstacles might be getting in the way, that might lead to that perception/conclusion by my colleague. I asked for some crowdsourcing information and input via Twitter, asking why does lean seem to be perceived as harder in the NHS, and more likely to fail than in other health systems? (I didn’t exactly word it like that in 240 characters, but that is what I was trying to say, my Twitter wording probably could have been better given some of the replies, sorry about that, my learning for another time). Nevertheless, rather pleasingly to my surprise, it has been one of my more directly actively engaged with tweets for quite a while (excluding RTs etc), so the question seemed to resonate.

To begin with, I had a few responses about why lean fails in healthcare, and I have also explored this before in my blog here and there are many research studies also examining the barriers to lean healthcare, some of which were tweeted via links (I haven’t added them here, too many). Thank you so much for the responses and thoughtful replies I received, they were very much appreciated on a very long train ride. Responses included: ‘healthcare is a service not automotive production’, the complexity of healthcare delivery, perceptions of top down control from lean, views that lean is (falsely imho) about costs, money, tools rather than people, relationships, networks, quality and care. And of course the essential role of leaders in lean transformation and improvement work, this last point I will return to. Some of the responses that tried to delve into my question about lean improvement in the NHS were quite interesting too. I feel like they mostly fall into four main obstacles connected to the (English) NHS context. These are 1) workforce protectionism 2) policy 3) money and 4) time/resources. There might be more and you might disagree, that’s ok, I’d like to know more about this. There might be loads of ideas still missing too.

First obstacle, a number of people described a resistance to improvement work within the NHS. Specifically because it is perceived, for whatever reason, as negative. Connected to the managerialism developed in the NHS following the Griffiths report during the beginnings of neoliberalism in the Thatcher era. Described as a ‘managers vs clinicians’ narrative of managers enacting unnecessary control, bureaucracy, and burdens. It may have led to a view that lean, specifically, is a way of furthering this neoliberal agenda because of its perceived exclusive focus on waste and defect reduction, accountability, transparency and checklists. Therefore, it was argued in responses, lean must be resisted to protect the professional clinical values of medicine and retain longstanding traditions. Others argued that such a protectionist viewpoint has led to some closed minds unwilling to acknowledge different ways of doing things or openness to change, even when it is clearly in the patients interest perhaps due to previous efforts facing problems and challenges and a fear of having to face similar things again. In the same vein, some feedback suggested a lack of humility from healthcare staff, unwilling to learn from others or from outside as the NHS can do it all itself anyway, if it chooses to. This was stated to be alongside a culture of deference, denial and an unwillingness by many to rock the boat. Some also indicated the arrogance and dogmatic approach from those coming in from outside with a packaged lean approach who are unwilling to adapt their ‘way’ to better suit the NHS context and listen to local expertise and previous experience. (My apologies for quite possibly being in that last category when I first joined healthcare, it was unintentional). Maybe you agree with this, or maybe you don’t, or maybe you can see why these points may have some wings. I’m wondering what others think about these lines of argument.

Second obstacle: policy. Lots of feedback suggested that they are only trying lean because they have been told to do so. That is, their organisation is part of a national programme, the regulator says so, or their execs say so, or it’s free support from a supplier but they are unclear as to why they are trying to become lean and what the purpose is. Some responses indicated that they think their organisations are only saying they are doing lean as window dressing for a cost improvement programme, often locally branded as ‘waste reduction’. In addition, it was suggested that they see little evidence of the second lean value of ‘respect for people’ in action at the sharp end of the work, with an emphasis on a technical approach and performance measurement instead of the socio-technical elements of building improvement capability to deliver improved quality. Perhaps indicating little fidelity in taking an improvement approach based on lean thinking. Responses also suggested that no matter what is discussed on twitter, at national conferences or in public meeting rooms with external stakeholders by leaders of their organisations about their lean work, in practice… not so much seemed very real to them. Patient partners in particular were the most scathing of this, suggesting they observe little ‘real’ dialogue of what ‘value to the customer’ really is, and see little sharing of power in redesign work and that lean can be enacted in a dogmatic way.

It was also suggested that policy makers and wider system stakeholders have little real understanding, or experience of lean and don’t lead by example in their own work. This, it was claimed, means that unrealistic timeframes and result expectations ensue, and that jargon and lean terminology can be used inappropriately, conflicting programmes can become established that clash and overlap, and that system wide leaders and educators don’t lead by example in their own work. What would a lean commissioner, lean knowledge network or lean regulator look like for example? All these leadership choices and acts suggesting to some healthcare staff that a commitment to lean healthcare is rather superficial, when only those at the sharp end of care need to reduce waste and work smarter, yet the wider healthcare system and leadership does not. ‘If they won’t commit, why should we? Let’s just put temporary contractors into the lean work, they might not have much experience of healthcare, and few relationships, but well this ‘programme’ might not last that long. Why take the risk and waste our effort? It will probably just be a fad, anyway’.

Third obstacle: money. This is mostly what I have been thinking about. When I worked in manufacturing, it felt pretty much an accepted given that lean was a growth strategy, that is, it was really helpful for productivity though error and quality issue reduction. So reduce the errors and defects and waste, delays and frustration for staff and customers associated with harm and rework and then use that capacity to make and service more demand. I don’t remember ever being asked to work on anything that was pure cost cutting or efficiency that was using lean (ie now you have freed up the capacity, cut the jobs, close the factory, release the cash). I did work on some massive reconfigurations that did close facilities, to help make others more economically viable (said the narrative) but these were very traditional cost improvement programmes, were not based on a lean approach and were driven by external management consultancy and restructuring firms.

In healthcare, a growth approach with lean might mean that the financial benefit would be delivered through harm and error reduction or a waiting time reduction process where money is available to pay for the increased throughout (income growth), and perhaps where there may be fewer concerns about over-treatment or equity. ‘Pay for use’ healthcare, such as that in the US might fit that criteria. But in the NHS where the total funding pot remains the same, more money for a unit or service becoming more productive (possibly under payment by results), may sometimes mean a breach of contract for over-performance, being unpaid for the additional activity and that funds for a service elsewhere need to be diverted to pay for the work, perhaps from a community service for prevention to acute hospital treatment. Arguably the opposite money flow to that envisaged in the Long Term Plan and other models advocating a shift towards prevention and community models of care.

Finally, some responses also said that lean costs too much (and then confusingly that lean work is insufficiently resourced) and takes too much time. These ideas may or may not be true, and I suppose any improvement work will need resourcing and take time; and much improvement and change work has variable results so I don’t think that these issues are ‘only’ lean issues in healthcare. And of course there would be an opportunity cost of doing nothing with continued harm and risk to patients, even if that had no direct costs. Responses also noted that the perceived urgency to ‘do something’ and the ‘lack of time’ can lead to a knee-jerk response of bringing in and imposing a new ‘package’ of solutions, as it can be perceived as that there isn’t enough time for staff to work through the issues for themselves using an improvement approach, such as lean. This potentially adds to the perception of ‘lean in name only’, with no respect for people and a lack of listening. Some also pointed out that funds to pay for lean and improvement expertise in the NHS can be more limited than in other healthcare systems such as the US. This could lead to more temporary rather than permanent teams, accompanied by a short term programmatic rather than systematic approach. Perhaps also with rapid staff team turnover rather than the longevity of lean teams building long standing relationships and local knowledge needed. Responses also noted that a lack of resources and money may also contribute to a lack of leadership and management capacity and team capacity to engage in improvement activity, with no ‘slack’ left to engage as workforce gaps grow.

What did I learn from this Twitter enquiry? What might this mean for lean healthcare in the NHS and/or for wider improvement work in healthcare? For me reflecting now and thinking how can I finish this blog, I’m noticing that leadership is perhaps an foundation to all these perceived obstacles and many experiments of enhanced ways of leading for improvement might help us to see what we can learnt get around these obstacles.

For example: Leadership for improvement that engages staff and patients/service users in discussion about the purpose of lean (and other improvement) work and communicates this repeatedly and often. Leadership that challenges and engages with unspoken (and imho mostly inaccurate) assumptions about what lean is; leadership that takes personal action to learn to practice lean thinking and improvement with fidelity by doing, to understand what lean can do and what lean can’t, learning to understand lean’s limitations as well as its potential. And system wide leadership that thinks hard about its role and gestures in supporting or inadvertently undermining learning about lean practice. Leaders have a choice with all improvement work, including lean, to engage and learn with fidelity, genuinely partner with service users and to make a personal commitment to improve that cannot be substituted or delegated.

To borrow a quote from a wonderful friend, rather than assuming it is lean that fails in healthcare, perhaps healthcare leaders fail lean.

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