News / News analysis: Making a lean start

If you’ve been to an NHS conference in the past few years, chances are you will have caught at least one session on Lean. You will remember the ‘before’ photos of the cluttered sluice room, the unruly, overflowing linen cupboard or the lab in which pieces of equipment often used together were at opposite sides of the room. And you’ll recall the ‘after’ shots: clean lines, uncluttered work spaces and, most of all, happy, motivated, more productive staff.

It seemed as though trusts had everything to gain by introducing Lean, yet perhaps because the service was enjoying unprecedented levels of growth, the process never really took off. Now that monumental efficiency savings are needed, its time may well have come.

Perhaps Lean sounds too easy. A lot of it is common sense – whether decluttering storage rooms or streamlining care pathways, the result should be happier patients being treated more safely by contented clinicians and support staff at less cost.

The straightforward nature of the Lean process and its potential to generate savings and improve quality were highlighted in a half-day HFMA FT Finance technical forum in October.

Forum chair Jeremy Butler, the deputy chief executive officer of HEFT Consulting, a trading arm of Heart of England NHS Foundation Trust, said: ‘We can be sure we have got to get on with the efficiency programme and we have got to do it safely.’

Lean fitted well with the QIPP (quality, innovation, productivity and prevention) programme, he added. ‘It’s about doing the right thing and getting it right first time. It’s about safety and efficiency.’

Paul Hetherington, director of performance and service improvement at Alder Hey Children’s NHS Foundation Trust, said his trust’s adoption of Lean processes was prompted by a ‘burning platform’.

Before payment by results was introduced, the trust had not experienced financial difficulties but suddenly it faced a potential £20m deficit during the incremental implementation period.

He added that there were parallels between Alder Hey’s situation then and the difficulties the wider NHS is facing now – the trust needed to cut costs but wanted to maintain the quality of its services.

Mr Hetherington’s team began to seek savings through more traditional service improvement mechanisms in 2005/06. Personnel were picked carefully to include staff who would champion service improvements, while managers ensured their time was freed up to allow them to get involved.

Mr Hetherington admitted that after the first year he suspected the scheme was not truly sustainable in the long term. It had been a success – generating more than £2m in savings – but it relied too heavily on the energy of the advocates.

A review of the available mechanisms concluded that Lean was the way forward and in 2007 the trust began to transform itself using the system. Importantly, the initiative was board-led, he said.

There were five major workstreams, which included areas such as discharge and governance, that were supported by a raft of rapid improvement events. The discharge value stream, for example, included work on increasing bed occupancy. When it began in February 2008, this was at 75% but by the third quarter of 2008/09 it had increased to 85%.

The results were impressive. The trust achieved the 18-week referral to treatment target ahead of time in March 2008. ‘When we started we were only seeing 45% of patients within 18 weeks,’ said Mr Hetherington.

By the end of quarter three in 2008/09, day case activity had increased by 15% and elective activity by 6.7%. The trust made productivity gains of more than 5% and the average length of stay for a day case patient has been reduced to three hours. The Lean programme was a key contributor to 15 of the 30 lines on the trust’s internal savings plan, he added. By month nine in 2008/09, direct savings and income raised had generated an estimated £3.88m, a return of 13:1 based on costs of just under £300,000.

The trust’s enablers value stream focused on reducing the time taken to perform and report the results of diagnostic tests. Reporting of MRI scans, for example, fell from three days in September 2007 to one day in the second quarter of 2008/09.

So where does the trust go from here, given the continued pressure on budgets? Mr Hetherington told the forum his team would revisit and refresh existing value streams, while ensuring the programme aligns with the trust’s strategic objectives. There are 20 new workstreams aiming to simplify patient flow in every area of the trust, not just day cases, and the trust is also developing a capacity planner.

‘The strategic approach is the best way to do this. Set high targets – when you have a Lean process in place set your targets above NHS standards because it makes achieving NHS standards an awful lot easier.’

The conference also heard from Jim Hearn, head of Lean at HEFT Consulting. He said the Heart of England trust did not introduce Lean to avoid a financial crisis but because it wanted to become

more efficient. The trust is now at a different point in the Lean process; it is trying to ensure the Lean philosophy is part of each staff member’s daily routine.

‘Lean should take over the organisation. Where an employee notices we are doing something wrong that puts the patient at risk, or something that simply frustrates them, they should have the permission, the skills and the time to do something about it,’ he told the forum.

The benefits should be immediately apparent, he said. ‘We employ 10,000 people and if every one of them took five minutes each day to do this, do you think I would need to be tracking improvements or measuring things financially?’

Mr Hearn said the NHS should aspire to the level of excellence offered by web search engine Google, which provided a high-quality service for free.

‘By focusing only on the things that add patient value, we create the highest quality in the least time and at the lowest cost,’ he told delegates.

Lean working may sound obvious, but as the NHS looks to eke out billions of pounds in savings, interest in the process and similar tools is sure to grow.