Boosting efficiency in the age of austerity

Despite the crowd pleasing announcements in the comprehensive spending review that NHS budgets would be protected, the reality is that the increase in spend from £98.7bn in 2010/11 to £109.8bn in 2014/15 represents a real growth of only 1.3 per cent when inflation is taken into account.
Within this small increase is the need to identify £20bn worth of real efficiency savings. While large chunks of this will be achieved through the wholesale removal of some non-frontline services such as SHAs and a variety of arms length bodies, there will still be a need for individual organisations to deliver a substantial part of the overall savings required.

Delivering front-line efficiency improvements can be achieved in one of three ways – the unilateral closure or reduction in services, under-investing without reducing capacity, or transformation. Of these three options the first two are the easiest to implement but don’t necessarily lead to the best outcomes for patients and staff.
The third option, transformation, is focused on changing the way that services are planned and delivered. Helping teams to move forward needs some form of structured approach and the rapid adoption of Lean within the healthcare sector over the last six years shows that it provides a useful transformational change framework if used effectively.
The starting point with Lean is that any use of resource which does not create value is wasteful and should be challenged. To be successful, healthcare managers have to overcome their limiting beliefs about risk, performance and accountability.
The problem is that the adoption of Lean to date has predominantly been localised within individual organisations or even within individual departments. The use of Lean to drive whole system transformation has been hindered by a pseudo-competitive market that has prevented organisations from working together to transform, rather than just tinker with, existing systems. This localisation of Lean has produced islands of excellence that are difficult to sustain. Often, problems are simply transferred upstream or downstream because of the failure to involve partners and providers outside of the initiating organisation.

Delivering the QIPP agenda
The financial crisis is providing uniform pressure on health and social care organisations to transform performance. However, this should not just be about delivering the same services for less money. The successful application of Lean can simultaneously deliver all aspects of the QIPP (Quality, Innovation, Productivity & Prevention) agenda. Lean can change the whole system so that care is provided in the most appropriate setting, duplication and delays are eliminated, patients are engaged and pathways are streamlined.

Capability, confidence, culture
The opposing pressure to the use of Lean to support whole system transformation is related to the ‘three Cs’ – capability, confidence and the organisational culture.
Capability is concerned with having access to the skills internally to initiate and lead a Lean programme without creating a dependence on external organisations and advisors. This means assigning people a role in leading transformation rather than tacking it onto existing responsibilities, and then training and supporting them to lead transformational change programmes. This will require as much thought as you would give to the appointment of a senior manager or clinician because if you get the wrong person the whole process is undermined.
Confidence is about not getting stuck in the analysis trap. Whole systems transformation brings with it the need to work across organisational and funding boundaries. This increases the probability of calls being made for in-depth analysis before any real change can occur, but the production of reports costing hundreds of thousands of pounds are more often used to stifle innovation and prevent progress rather than accelerate it.     
While Lean obviously requires some scrutiny before implementation, it also requires you to address the underlying issues that lead to the brakes being applied through excess analysis. Typical concerns include loss of control or income, allocations of additional work without corresponding changes to funding, and differences in organisational priorities. Overcoming these requires a lot of work to be put into managing relationships and creating an overall Transformation Map.

Differences in cultures

Perhaps the biggest barrier to the successful adoption of Lean across whole systems is caused by differences in organisational cultures. Within this area probably the most damaging issues are where there has been a history of adversarial relationships or where there is an underlying perception that one organisation or another is ‘out of touch’ or worse. These perceptions are rarely true and often very unhelpful. One of the most beneficial aspects of the successful application of Lean is the requirement for it to be delivered by teams of people working together, cutting across boundaries and through stereotypes.
While the root cause of the current financial crisis cannot be placed at the feet of any individual organisation, the solution can, with the right support and using a Lean approach, be in their hands.

Mark Eaton is managing director of Amnis UK

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