Lean Failings
John Seddon
on the Predictable Problems
now facing the NHS
http://www.systemsthinki ng.co.uk
August 2008 - October 2003
Presented by
People and Process Limited
http://ww w.peopleandprocess.com
Introduction and Challenge
John Seddon of Vanguard Consulting, UK has taken the work of W Edwards Deming and Taiichi
Ohno, the father of the Toyota Production System, and adapted, as opposed to applying, it to
service organisations.
This is a collection of his newsletter articles highlighting what have become predictable problems
resulting from the introduction of “lean tool thinking” into the UK's National Health Service.
Their subject matter ranges from the imposition of arbitrary targets through lean tools to the very
real effects both have on patient experience. The articles are presented in reverse chronological
order dating from August 2008 back to October 2003 so that you can see first the current and very
real problems being experienced by employees and patients of the NHS then the predictive
analysis that foretold exactly those problems...
Timely reading
This collection is timely reading for New Zealand health managers and practitioners as we begin
the wholehearted application of those same tools and techniques that were, and continue to be,
used in the UK with significantly less than desirable results.
The lessons for thinking managers are many and I trust that you will find them saluatory.
Question assum ptions
It is not too late to question the flawed assumptions behind the programmes being put forward by
the Quality Improvement Committee of the Ministry of Health. To do so is relatively simple.
Every time you are presented with a new “lean tool”, simply ask, “how does this help me
understand clinical demand and clinical outcomes from the patient's perspective?”
Precisely because lean tools have been adopted from the world of manufacturing, you will
invariably find that the answer is, “they can't”.
If a new tool cannot help you understand clinical demand and clinical outcome from the patient's
perspective, it is of no value to either you or the patient and is therefore not deserving of your
valuable time.
Moreover, there is no need for New Zealand health to repeat the mistakes made in the UK NHS,
the NZ public deserves better. A hospital is not a factory and an end-to-end health system not a
supply chain, despite initial appearances and assumptions.
The articles contained in this document together with the recommended reading will provide you
with the concepts necessary to develop a truly world-class health system.
Recommended further reading
Newsletter articles are necessarily brief. For a fuller understanding of the thinking behind the
thoughts, see:
●
●
Deming, “Out of the Crisis”
Seddon, “Systems Thinking In the Public Sector”
I wish you good reading and associated good thinking.
Stephen Hay
People and Process Limited
Making Change Safe
PO Box 30-169 . Wellington . New Zealand
+64 212 538 064 . [email protected]
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Table of Contents
In troduction and Challen ge.................................... 2
The mon ey is being spent on IT.......................... 14
The experience you get with th e NHS................4
If things look bad, change the measures.......... 14
Targets damage your health...................................4
Tool heads at work in the NHS...........................15
How bold are th e managers?.................................4
Ministers drive up health costs...........................15
Did your nurse smile?.............................................. 5
The blame ga me (NHS).........................................15
A 'bed manager' laments.........................................5
The NHS is amongst th e most sick....................16
A patient laments....................................................... 6
The doctor cannot see.............................................16
A mother laments.......................................................6
Minister defends targets........................................ 17
A spouse la ments....................................................... 7
The consequences of health policies..................17
CSCI inspectors caught cheating.......................... 7
Ambulance service gets the wrong solution...17
NHS to sack 'failing managers'.............................. 7
Ministers interfere with scanning....................... 18
A lament from the NHS........................................... 8
Will new Labour save the NHS?.........................18
How many miles does a nurs e walk?.................. 8
Ministers push up costs of NHS.........................19
NHS Direct compounds mis ta ke.......................... 8
NHS IT sys tem costs up.........................................19
Coercing doctors to behave stupidly...................8
And govern ment drives the human costs up. 20
Targets are killing people........................................9
The NHS don't want improvement................... 20
Is the penny droppin g on NHS targets?.............9
A and E demand grows, but why?.....................20
Tool heads get it wrong in the NHS..................10
Waste mon ey while doing nothing for our
health...........................................................................20
Hospital cheats appointments............................. 10
NHS is going down th e tools route...................10
Womack on sustainability.....................................11
“It's a system problem”..........................................11
Ambulances making their numbers..................11
Lean in th e NHS.......................................................12
Your doctor is not immune...................................12
'Lean' health care requires supervision............13
NHS joins the tools bandwagon.........................13
The management factory ruins your health....14
I'm glad I didn't go to the NHS...........................22
Another wa y to cheat our h ealth........................ 22
Will IT work in health?..........................................22
Doctor reveals the truth......................................... 23
Minister does the wrong thing righter..............23
The real causes of was te........................................23
Another example of designing waste in..........24
NHS Direct.................................................................24
NHS 'Direct'?.............................................................25
A visit to the Modernisation Agency................26
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The experience you get with the NHS
A reader writes:
“Late last year, after some time of suffering from pain in my gut, I visited my doctor for a check up.
The doctor examined me and asked me, what I thought was wrong.
'I think it is a hernia, or maybe a problem with my intestines, or, at worse, cancer' I told him. 'You
were right the first time -you have a hernia.'
I asked the usual questions: Will it go away? No; Can I do anything to help it? No; Will it get
worse? YES.
The doctor told me that, because of cuts in the health service, he was not allowed to refer me to the
local hospital. He recommended a special support truss for me to wear, during my work. The work
I do is physical and wearing the truss made some of the jobs that I had to do, very painful as the
truss would 'dig in' my stomach, and push hard against the hernia. I re-visited my doctor and told
him of the problems that I was having, and he re-iterated what he told me previously and
suggested that I should complain to my local MP.
I wrote to my MP and explained the problem that I was experiencing. He replied and also wrote to
the Chief Executive of my local hospital trust. A reply from the Chief Executive contained 95%
waffle - this was my doctor's interpretation of the letter.
The letter ended with: 'If Mr. [X] feels strongly that he would like to be assessed, his GP is free to
refer him to the hernia clinic'. This information is a complete reversal of what the doctors at my
surgery have been told to say. My doctor wrote to the hernia clinic and a few days later a date and
time was set for my assessment.
The day duly arrived and I took time off work to go to the hernia clinic. I handed in my letter to
the nurse and sat down in the waiting room. After a quick examination, the consultant agreed that
I did indeed need the operation. I was given a folder of my notes and took these to the pre-op
assessment department. I handed these to another nurse and sat down in the waiting room. It was
only a matter of weeks from that time before I was admitted and had the operation.
Why, after paying my National Health stamp for more than 40 years, should I have to fight to get
the necessary treatment?”
(Vanguard News, August 2008)
Targets damage your health
Writing in the BMJ a hospital consultant gives examples of the ways in which targets have
undermined patient care. It is not the first evidence and it won't be the last. But I'm confident the
regime will ignore it. “Harms of target driven health care”, Nigel Rawlinson, consultant in
emergency medicine, http://ww w.bmj.com
(Vanguard News, August 2008)
How bold are the managers?
I was persuaded to bid for work in an NHS organisation. I was assured people were aware of and
ready for the challenges offered by Systems Thinking so I went along to explain how Systems
Thinking works and to make it clear that the work in 'check' would reveal how current 'system
conditions' (targets etc) were causes of waste.
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Because of this I suggested we should open communications with the Department of Health as we
would need the freedom to do the right thing and stop doing the wrong thing when the work
moved to re--design. Despite the enthusiasm of the top team the director of finance black-balled
the idea. His view was the work would lead to publicity which might be politically 'difficult'.
So there we are, when offered the opportunity to learn and design a system based on purpose from
the patient's point of view some managers would prefer to do as they are told, not rock the boat
and ignore any adverse consequences for their patients.
I am reminded of being in a seminar where another finance man working for a Trust said: “We
might make a loss on A and E”. How can anyone conceptualise A and E that way?
(Vanguard News, August 2008)
Did your nurse smile?
The Department of Health has announced that nurses are to be scored on how compassionate they
are towards patients. The health secretary, Alan Johnson, obviously believes service is a 'smile'
thing and thus a 'people' thing. How wrong he is.
In any system you learn that the 'smile-ability' of the front-line staff is governed by their system.
Just this week a systems thinker told me of an example: A study of demand in a service centre
showed workers were dealing with lots of failure demand (so lots of customers already unhappy)
and lots of value demand that, by design, the workers were 'not allowed' to service - managers had
put in procedures which meant the work must be passed off rather than resolved. These two types
of demands amounted to more than 80% of their work. Like Johnson's nurses, these workers were
subjected to a survey, measuring how well they 'smiled'. To complete the wrong-doing, the survey
scores lead to bonuses; so these poor workers could never earn a bonus. And the responsibility is
with the managers, whose bonuses are not affected.
When you discover such absurdities in the private sector, you change things quickly. Johnson is so
far away in the management factory that he will never learn the simple truth that peoples'
behaviour is a product of their system and his nurses' inability to smile is more to do with him
than them.
(Vanguard News, July 2008)
A 'bed manager' laments
A reader sent me something he saw on a message board:
'I am a bed manager [in the NHS] and I despair at times. We are constantly under pressure to meet
government 4 hour targets, yet patients are still being admitted that could have been treated by
their GP or seen as an outpatient. No wonder there are not enough beds, and no wonder patients
are still waiting unacceptable periods of time on an uncomfortable trolly in A/E!!!'
And Johnson wants to know if the people smiled.
Why do we have 'bed managers'? One sure way to sub-optimise a system is to try to maximise
utilisation of equipment.
(Vanguard News, July 2008)
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A patient laments
A reader writes:
'In May I had my annual eye test. Everything went well and the optician recommended that I have
a check up at [the hospital] to be on the safe side. The optician would write to my GP asking him to
refer me and he in turn would write to the hospital. The optician also asked me to contact my GP
after one week to make sure the letter had arrived and had been processed by my GP, which it had.
So far, so good.
Then on 20 June I received a letter from the hospital. The hospital had practiced 'lean' by sending
two appointment letters in the one envelope and each asked me to telephone the Eye Clinic office
if I could not keep the appointments.
So on 22 June I called the office and said I was confirming the 1st appointment on the 16th July but
unfortunately I could not attend the 2nd appointment on the 22 July as I would be on business in
the US for 2 weeks. Therefore could I possibly have an earlier or later date? I had my diary open
and was ready to proceed. The very kind receptionist said there were no earlier appointments
available as that particular clinic was always very busy. No matter I said, I can come on another
day after my business trip. Then she told me that was not possible because they would not meet
the targets which had been set and I would have to contact my GP to start the referral process all
over again. When I gently pushed her on the matter she said she could not help and they had to
meet their targets.
On speaking to my GPs receptionist (4 telephone calls, numerous voice messages and buttons
pushed later) was told 'oh, that is the NHS targets again, the system does not work.'
And Johnson wants to know if the people smiled.
(Vanguard News, July 2008)
A mother laments
A reader writes:
'My child was referred to an orthodontist. After waiting two and a half years, an x-ray revealed unerupted teeth that need hospital extraction. A week after the referral letter was sent, I was required
to ring the call centre to get an appointment. They told me they did not actually make the
bookings, but the dental bookings staff would ring me back. Later that week, a letter arrived with
an appointment date which my child could not attend due to a school trip. I rang the number on
the letter, got a new appointment and enquired about the telephone call I had been expecting. I
was told that 'we have to ring three times and if no-one answers we just send a date'. They had
rung three times one afternoon when I happened to be out. What's worse is that this appointment
is for yet another assessment by yet another dentist and we will no doubt be back on the merry-goround just to get a treatment date.'
She went on:
'My child has a long term requirement for podiatry services. His review dates are dependent on
how fast he grows; we ring the call centre for an appointment. On one occasion I was told 'the
system' had discharged him and we needed to go back to the GP to get re-referred. (I refused, we
did get an appointment after I was warned not to leave it 'too long' again). On another occasion the
call centre booked him into a different clinic. I queried this and was told 'It has changed. We have
to book according to where you live'. We attended this clinic and after being reviewed the
podiatrist told us she was 'not allowed' to prescribe this type of device as they were 'too expensive'.
So instead we had to go to a different clinic, see another podiatrist and get the expensive devices
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replaced using an even more expensive process.'
And Johnson wants to know if the people smiled.
(Vanguard News, July 2008)
A spouse laments
A reader writes:
'Some 3 years ago the NHS had an initiative called agenda for change, which resulted in most
people being down graded and getting a pay cut. Naturally they all appealed - this took 18 months
of NHS time and cost a fortune – and most got pay increases on appeal. Now the bad news - the
NHS did not pay the increases, and in some cases still haven't.
So in my wife's case, many e-mails to the trust's CEO resulted, after about 6 months, in the backpay being approved. Incredibly, in spite of the CEO instructing a senior manager to get it sorted, it
still took months. Estimates of the back pay due were wrong, and so the mill kept grinding.
Worse to come! People who retired 18 to 30 months ago were paid a pension based on the incorrect
lower salary. Getting the pension sorted out is proving impossible because payrolls were
outsourced. The NHS blames the payroll Company, they don't answer their phones, and an e- mail
sent 3 weeks ago is unanswered.'
And Johnson wants to know if his wife smiled.
(Vanguard News, July 2008)
CSCI inspectors caught cheating
The Today programme ran a report about Commission for Social Care Inspection inspectors being
ordered by bosses to up-grade their evaluations. Up-grading inspection evaluations makes it look
as though the inspection regime is doing its job - things are getting better.
But the truth is compliance with CSCI's requirements has driven massive waste into the adult care
system. I have explained the same to Ivan Lewis, the minister, and David Behan, the man
responsible for adult care at the Department of Health, and erstwhile originator of CSCI. What did
they do? I think you can guess.
(Van guard News, June 2008)
NHS to sack 'failing managers'
For some time it has been difficult to fill top jobs in the NHS. The top six targets were considered
'P45' issues (the form you get when you are sacked). Who wants a job where you might fail? The
repetition of this bullying tactic is to assume, of course that the managers make a difference when
the truth is the performance of the NHS is a consequence of the way it is designed and managed
and that has become the province of the Department of Health.
Bright kids (they call them SPADS - special advisers) who know nothing take the ministers' ideas untested un-researched notions with assumed political appeal - and rain them down upon NHS
managers with the threat of sanctions for failure to comply.
Who should we hold accountable?
(Van guard News, June 2008)
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A lament from the NHS
A reader writes:
'As an NHS employee of 22 years standing it is a source of bitter frustration that we seem to have
bred a generation of senior managers fed on a diet of 'deliverology' and incapable of taking the
courageous step of challenging the sheer, patent wrong-headedness of so much of the guidance
which is delivered from The Centre. 'World Class Commissioning' is the latest NHS big idea which
has not the slightest connection with improving quality, value or the citizen's experience of
healthcare. However, reputations will be made and careers will flourish on the back of it I have no
doubt. Meanwhile, vast amounts of money will sink into the sand.
I am someone who, in spite of everything, is still passionate about the NHS, but have reached the
end of my tether with the waste, mismanagement and cowardice which characterises much of the
management I see around me.'
(Van guard News, June 2008)
How many miles does a nurse walk?
The chief executive of an NHS Trust proudly told me he had the tool heads in. One of their key
projects was to study how many miles a nurse walks. Is that the purpose of the system? You
couldn't make it up.
(Van guard News, May 2008)
NHS Direct compounds mistake
NHS Direct is not getting the calls it expects to achieve its corporate plan. So what do top
management do? Brainstorm ideas for how to get more calls or make more calls; the problem they
want to solve is how to use the resource to meet the plan. One idea is to ring people who are longterm ill to see how they are doing. How dumb is that? From the patient's point of view it will
disturb their current service and is bound to create more demand.
People in the NHS call it NHS 'Re-Direct', because they have noticed that it doesn't solve many
problems and most often people are sent to other services: GP, pharmacy, A & E etc. Thus the
number of transactions goes up and hence the costs of health services go up. Having made the
mistake of creating something that doesn't work, these managers compound the problem by trying
to find it more stupid things to do.
I expect they are tied into an agreement with the Treasury that drives them to behave this way.
(Van guard News, May 2008)
Coercing doctors to behave stupidly
A reader writes:
”I damaged my knee. I went to the GP who referred me to a hospital and, as part of the process,
took me through the options under the 'patient choice' initiative. Basically I could go to just about
any hospital in London, but guess what I said? I'd like to go to the nearest one to where I live.
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After the consultation he gave me a survey to complete along with a freepost envelope to return it
to Ipsos MORI (the research company lucky enough to be riding this particular gravy train!). The
survey says...
'You were given this questionnaire because your GP has referred you to see a specialist at a
hospital'. The questions are:
Q1. Think about when your doctor referred you to see a specialist. Did your doctor talk
with you about a choice of hospital for your appointment? Yes / No
Q2. Are you male or female?
Q3. How old are you?'
That's it, no other questions.
I read it and just sat staring at it. I cannot possibly imagine why this survey exists other than to
"prove" that the patient choice initiative is a roaring success. As for the research company, how can
they sleep at night knowing that they have colluded with such a waste of money, do they have NO
professional pride?”
He also told me there is a freephone number to call (available in 11 languages) and a website for
anyone who needs help filling in the questionnaire. If people need help with these questions they
ought to go straight back to the doctor.
(Vanguard News, April 2008)
Targets are killing people
On February 10th Simon Caulkin's column in the Observer reported research that shows while
targets show improvement in the NHS, mortality rates increased. Yes, targets kill people. The
research was published in the Economic Journal (no. 118, January '08), pp 138-170. Who should we
hold accountable?
(Vanguard News, March 2008)
Is the penny dropping on NHS targets?
A reader writes:
“I think that slowly, in some parts of the NHS, the penny is beginning to drop about targets,
although I mainly hear this from NHS managers for whom the penny drops, and then who
despair. I also have bad days, for example I recently asked someone very senior in the Department
of Health whether they would drop the 18 week target once patient choice had become embedded
in the system. “Targets are a vital tool to reduce waiting times” I was told in a patronising way, as
if I were a 5 year old retard.”
I think he is optimistic. In one part of the country the obvious cheating going on where people are
kept in ambulances to avoid starting the accident and emergency clock (target = 4 hours), the
'solution' has been to target ambulances on putting people in to accident and emergency within 15
minutes. In another part of the country they have realised that admitting people into hospital from
accident and emergency, to avoid failing the 4-hour target, is driving up costs (hospital admissions
mean £800 for the hospital rather than £80 for treating people in accident and emergency). Their
'solution'? To agree a lower tariff for these cases.
Both examples of doing more of the wrong thing, not solving the problems.
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And in the meantime the ('lean') tool heads are making hay in the NHS, promising that lean tools
will help managers meet their targets. Last week I met an NHS chief executive who told me his
tool heads were counting how many miles a nurse walks. Obviously he thought this was good
work, when you describe this to any systems thinker the response is incredulity.
(Van guard News, February 2008)
Tool heads get it wrong in the NHS
I was sent a note by a systems thinker in the NHS, telling me the recent 'Lean Healthcare Summit'
reached the following conclusion:
“There is a lot more to Lean than tools and Rapid Improvement Events; Lean actually involves a
very different approach to leadership, management and culture.”
Wrong. But it's the kind of rationalisation tool heads make. When you change the system, culture
changes automatically; it is as Deming taught, peoples' behaviour is a product of the system. In
that sense culture change is free. You change the system by helping managers learn how to act on
their organisation as a system – that is what leadership is about. Management starts with changing
measures, something the tool heads know little of.
People being guided by the tool heads will mistakenly invest in 'culture change' and the rest. They
think they have these problems because they have issues with people getting engaged with using
their tools and they don't know what to do with managers. The tools don't help people tackle
questions of purpose, they are assumed to have universal application. Ohno built a system, it was
(and is) a revelation. The methods he developed to solve problems he faced have been codified as
tools by the tool heads. They assume the tools can be applied to any system. In assuming that, they
miss the first requirement: to understand the work as a system.
Ohno insisted we should never codify method (write tools). He could foresee the consequences.
(Vanguard News, September 2007)
Hospital cheats appointments
A reader writes:
“I had an appointment booked with a specialist at Manchester Withington hospital for 16th July
and it had been booked for months. Last week I get a letter with a new appointment for 24th Sept.
Puzzled I phone to find out what is going on and check the 16th appointment is still OK. It
transpires that my 16th July appointment had been brought forward to 2nd July by a manager as I
had breached the eleven week rule. What rule I ask – the one that says you have to be seen within
11 weeks of referral is the reply.
Great logic except no one told me of the new appointment so of course I did not turn up – hence
the new appointment for Sept (11 weeks after I am logged as a no show I presume). The specialist's
secretary agreed that it was flawed logic, especially as she said “that all our clinics are over
subscribed”.
(Vanguard News, August 2007)
NHS is going down the tools route
Apparently many NHS organisations are attracted to the lean tools nonsense; people tell me there
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are many requests for tenders for lean tools training. Tragic. We should not expect much
improvement, and we should expect lots more public money being wasted.
(Vanguard News, August 2007)
Womack on sustainability
Many readers have sent me Jim Womack's latest newsletter in which he laments the failure to
sustain a change in a healthcare system. He describes talking to a manager who had 'Kaizen
Blitzed' the organisation's key value streams, with amazing results, but the results were not
sustained because the change was not “connected to the way the organisation was managed”.
Things regressed. We have seen the same in the UK. In one hospital, staff 'went back to the old
ways' and it necessitated a new layer of management to keep them in control. It amazes me that
people did not recognise this to be a symptom indicating they had the wrong answer.
Womack's remedy is to put in value-stream managers who periodically re-audit the value streams,
assessing the current state and 'visioning' a future state. This is no different from 'process owners'
in the days of TQM. It didn't work then and it won't work now. The answer is to change the system
– to change roles and measures so that the people in the system continue to develop knowledge
and, hence, improve. Sustainability is a design problem; you have to change the system.
(Van guard News, June 2007)
“It's a system problem”
This has been an oft-used excuse amongst ministers confronted with failures in our public services.
The latest example concerns a woman who died through atrocious out-of-hours care. She made
eight calls to the out-of-hours service, talking to eight different doctors. Each call was treated as a
separate episode; she had to re-count her symptoms and what had gone on with previous calls
each time she called. None of the doctors recognised that she had blood poisoning, which led to
organ failure. This tragedy was described as a 'major system failure'.
The doctors involved were punished, six will now go back to work (having been suspended)
following the 'review' and two are to be subjected to a performance review by their PCT. If it was a
system failure, the doctors should not be blamed, for they were working in the system; they were
not its architects.
My guess is this system was designed by someone who wanted to buy transactions, so it was
designed to do that. The architect lost sight of the system's purpose, perhaps driven to do so by the
bigger system's focus on cost. It is the architect who should be held responsible. “It's a system
problem” has become a mantra for avoiding accountability.
We have seen exactly the same in adult social care, every time someone seeks help they are treated
as through they are unknown, each is a 'new' transaction. Such designs drive up costs and worsen
care. Ministers are responsible for promulgating these designs through various agencies; managers
are responsible for implementing them. We must remember every system has a leader and the
leaders are responsible for their systems.
(Van guard News, June 2007)
Ambulances making their numbers
The stupidity of measuring the eight-minute response time has been all over the press recently
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(you get a tick in the box for getting there in eight minutes even if the patient dies). People
working in the ambulance service tell me this is causing some managers to send 'technicians' who
get there on time but can't help the patients (some die) and other managers work on what calls to
'exclude' from the eight-minute measurement. The latter, of course, leaves them open to making
the mistake of treating some events as not time-critical when in fact they are.
Both are examples of doing the wrong thing. The right thing would start with understanding
demand and capability. It would open peoples' eyes to the waste in the current service design. But
until the ministers get interested in that, the service providers will continue to do what they can to
cheat the wrong numbers – wrong in the sense they can't help you either understand or improve
the system.
(Van guard News, June 2007)
Lean in the NHS
The recent 'In Business' programme (radio 4) on the NHS 'lean' programme provided another
illustration of the problem with treating 'lean' as process improvement through tools. The main
method employed was the Rapid Improvement Event. Whenever I hear that phrase I am reminded
of what Deming (sort of) said: If you can do this in a week, why didn't you do it last week?
Of course what gets done in a week is superficial process improvement. As the programme
showed, many people don't 'get it' and some become actively resistant. The managers said we
should expect resistance (but it is a product of badly designed change) and they decided to stop
calling the change 'lean' and instead call it 'process re-design'. At least that is honest (as well as
foolish).
An NHS reader writes: 'I come across services where there is no management methodology and I
have yet to come across a management team with any understanding of the capability of their
service processes.'
Very disturbing, and something the tool heads won't help with. The answer to Deming's question
is: because of the system and it is that that has to change.
(Van guard News, February 2007)
Your doctor is not immune
A reader writes:
“My neighbour is a GP working in the family planning clinic. They have learned that when you fit
an IUD you check on it after a short period of time and then it is OK for 5 years. Meanwhile the
GPs practices are phoning these people up every year because the phone call counts as
'contraceptive advice' for which they get a fee. The patient then phones the clinic to ask what's
going on. Meanwhile the fee for fitting an IUD is so low that Gp's pass patients on to the, now
overloaded, clinic. Can't wait for more of King Tony's reforms.”
It is testament to the power of targets creating 'gaming' or 'cheating' that even people with
professional status find themselves bound to 'play the game'.
(Vanguard News, October 2006)
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'Lean' health care requires supervision
The NHS is experiencing a wave of euphoria over 'lean'. In the form this is taking - lean 'tools'
developed in manufacturing - this initiative will fail and that is a tragedy, for 'lean' has much to
offer the design and management of health care.
One indication that the 'tool heads' don't understand the problem is their assertion that the 'lean
tools will help the NHS meet its targets'. Targets, like all arbitrary measures, distort systems.
Instead of using targets NHS people should be using real measures, derived from the work, that
aid the understanding and improvement of that work.
A further indication that these interventions are doomed is the fact that the 'new process designs'
being piloted have required extra supervision, to keep people from 'slipping back' to what they
used to do. It illustrates that the 'solutions' are being worked out by people who then worry about
how to get others to do it. This is never a problem for Vanguard practitioners, for the right way to
intervene is to ensure the people doing the work are also responsible for designing it. It is to put
design in process, an essential feature of the Toyota System.
My fear is that NHS managers, duped by the tool heads, will think they have 'done lean' when
they have not even started. Taiichi Ohno must be turning in his grave. He taught us that what
matters is how we conceptualise the problems. NHS managers are not being taught any of that.
(Vanguard News, September 2006)
NHS joins the tools bandwagon
An NHS reader writes:
“It is clear that the management factory eggheads remain firmly entrenched by their latest,
frightening, initiative 'combining' lean and six sigma! I couldn't think of anything more likely to
exhaust, frustrate, bore and defeat all well-intentioned folks in the NHS. And they think they are
going to involve our demoralised staff with this kind of complex, deluded, overblown rubbish!”
He had sent me a document produced by some quango on 'lean six sigma'; it wouldn't have gotten
a pass grade from me. Another reader writes:
“Seeing Six Sigma promoted in the health Service makes my heart sink. Being new to the NHS and
an ex engineer I've seen what a mess Six Sigma makes of normally good businesses. For a number
of years I worked as a product manager for a supplier to [name withheld] and saw them swallow
the six-sigma bait hook line and sinker. Simple cost saving ideas suddenly took ages to bring in as
they had to go through the sausage machine and the benefits were held up as proving that six
sigma worked. Er no it just delayed implementing cost savings....”
I do hope the NHS people who are enthused with this nonsense take the time to read “Watch out
for the tool heads” available at: http://www.lean-service.com/6-23.asp
To promote manufacturing tools as though they have general applicability won't help where the
help is needed, changing the system.
One lean 'guru' says 'lean' might help them achieve their 18-week target. Fool. The target itself is a
major system condition that will be causing waste.
(Van guard News, May 2006)
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The management factory ruins your health
The NHS is (again) in crisis. Cost overruns mean people are being made redundant. Just like the
private sector, who gets to go? The people who do the work. It is no wonder the Secretary of State
for Health got booed by the nurses at their recent conference.
To cut costs the minister is also cutting the number of strategic health authorities from 28 to 10.
That might be at least doing less of a bad thing but the upheaval and establishment of the new
reporting structures will place a burden on the place where the work is done. The minister hopes
new 'foundation hospitals', which will work on the basis of payment by results, will do the trick.
But the truth is they are not paid by results, they are paid by activity; another way of ensuring the
system's costs will go up (again such cost management stops the system absorbing variety). And
finally, the minister is bringing us patient choice, which means being able to go somewhere else if
your hospital can't fit you in. Is this a 'choice'?
(Van guard News, May 2006)
The money is being spent on IT
The minister's £6.2bn NHS computer system has hit a snag. Accenture is blaming iSoft for delays
in the delivery of software. While Accenture blames iSoft a spokesman for the NHS suggested the
fault lies with Accenture. He was reported as saying he was 'surprised' by Accenture's decision to
call the delays to the project 'recent developments' given that iSoft warned about them two months
ago. He stressed that it is Accenture's responsibility as 'prime contractor' to manage the delivery of
services.
I have to say I told you so. [See Vanguard News November 2004] Getting IT companies to work
together is only one of the problems with this 'solution' when the rubber finally hits the road we
will see the others I forecast.
(Van guard News, May 2006)
If things look bad, change the measures
Apparently the Department of Health is consulting on new ways to measure NHS productivity.
Why? Because the recent Office of National Statistics report said productivity fell by between 0.6
and 1.3% a year from '95 to '04. As ministers have doubled spending this doesn't look too good.
Ideas being put forward include measuring waiting times and the patient experience. To measure
waiting times as a proxy for productivity is, simply, the wrong thing to do. I would have thought
DoH people would by now have woken up to the distortions created by this and other arbitrary
measures.
Have we any confidence these people know what they are doing? Their first step should be to
understand the 'what and why' of health service performance as a system. They would discover
the current measures are part of the problem and not the solution; in doing this work they would
have been obliged to implement system measures and would thus have a good idea about the
capacity and waste in the system. Then they could return with some confidence to solving their
current problem.
But I guess the current problem is political. So we should expect them to try anything that might
support the view that things are improving. And by the way, I have just heard from my people
working on our first NHS assignment. It looks as though the government targets on being seen
have focussed resources on the front end, creating a backlog at the treatment end – yes the thing
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the 'customer' wants. And, as I said in my book, we find no measures of demand and outcome, if
the NHS isn't there to deal with that, what is it doing? Watch this space.
Things look bad because they are bad. Ministers should be held responsible. What is the purpose
of this system, what have the ministers made it?
(Vanguard News, April 2006)
Tool heads at work in the NHS
People in the NHS who are following Vanguard's work have been in touch to get my views about
lean manufacturing tools being applied to the health service. Just as with the above nonsense they
tell me standardisation is offered as the route. There is talk of 'job families'. As I understand it this
is something manufacturers do to reduce variation – if things they make have similar parts it
makes sense for them to travel down the same flows. It might seem plausible for health services to
follow the same idea. But the thing you have to work on first is demand and you should develop a
type classification empirically, without reference to current 'treatments'. I spent two days on an
ambulance and saw for myself the waste caused by complete insensitivity to the nature of demand.
And the tool heads say nothing about measures, they are not attuned to the way the current targets
etc drive waste into the system. But that's because they are tool heads not systems thinkers. If you
have not read it already you can find “Watch out for the tool heads” at: http://www.leanservice.com/6-23.asp
(Vanguard News, March 2006)
Ministers drive up health costs
Private Eye reports that a primary care trust in Oxfordshire has followed ministerial instructions
and, consequently, driven up the costs of health care. The care trust bought a contract with a
private-sector provider for eye operations, largely cataracts. It was an attractive deal for the
ministers, more procedures at lower costs; economies of scale – a classic command-and-control
ideal. But the private-sector provider has only delivered a small number of the operations
contracted for. Instead of the five hundred planned in the contract, only ninety-three have been
carried out. This means the trust has paid £255,000 for £40,000 of work.
In their panic to meet the targets the care trust is now advertising over the radio (more costs) to
find people who need eye surgery. Perfectly usable services within the hospitals are passed over in
favour of sending the work to the private-sector contractor to make the numbers look right. More
costs.
If only Ministers had started with understanding the predictability of demand by type of
procedure and geography, a systems approach, they might have avoided getting this mess and
might have designed a service that meets the needs (demands) at the lowest costs. It might also
keep the hospitals open.
We should remember it is our money they are wasting.
(Vanguard News, January 2006)
The blame game (NHS)
Leaked e-mails reveal the IT people blaming managers for the NHS system being late and
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unworkable. Managers, they claim, keep changing the specification. It is a problem I have talked
about often, it is down to the way we go about IT. The use of specifications assumes both parties
actually understand how the work really works. If you want to read more about this see the article:
“Is IT bugging you?” In the miscellaneous section at: http://www.lean-service.com/6.asp
Last year “In Business” wanted someone to talk about why the new NHS IT system would fail, I
got the job. I summarised what I had to say in the November 2004 newsletter, which you can find
at: http://www.lean-service.com/6-news-0.asp
I have to say I told you so.
(Vanguard News, December 2005)
The NHS is amongst the most sick
A reader writes:
“The focus of NHS senior management on targets and 'choice' i.e. introducing more private
providers and restructuring (again) to facilitate this has gone into hyper-drive in the last two
months. It reminds me of a quotation from Dr. Bill Maynard & Tom Champoux in 'Heart, Soul and
Spirit' 'When what you are doing isn't working, you tend to do more of the same and with greater
intensity.'”
And Tony Blair laments his failure to push harder when it comes to public sector reform. What will
pushing harder do?
He also writes:
“It certainly isn't working - the £98 billion they have spent has produced a pathetic 3%
improvement in productivity. John Hutton isn't the sharpest knife in the box; these are not his
ideas. I'd like to know exactly who are the advisors behind the scenes who have convinced
Blair/Hutton/Hewitt/DOH that this is a sensible strategy, so that we can expose their ideas and
engage them directly.”
I met two such advisers earlier this year. They had been brought in from the private sector and
were tasked with a major restructuring of a national government service. I was told they were on a
bonus for completing the work; their behaviour showed they were more interested in 'delivery'
than whether it would work.
(Vanguard News, November 2005)
The doctor cannot see
A doctor wrote to the Daily Telegraph making the observation that the minister's 48 hour
appointment target was fatuous as the relationship between waiting times and appointments
would always be a matter of demand, how many people want to see a doctor, and supply, the
amount of doctor time available. We (in Vanguard) have had only limited dealings with the health
service, but the little we know suggests the doctor might find everything you find in other service
organisations if you know how to look.
Failure demand consuming doctor resource; failure to design against demand creating waste in
flows and, hence, loads of both types of waste. The doctor should first study demand in customer
terms, it might throw light on a better way to design health services.
In making his argument he shares the minister's paradigm and it is that which is the problem.
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(Vanguard News, September 2005)
Minister defends targets
Patricia Hewitt, the new minister for health was told by Jennie Blackwell, a delegate at the British
Medical Association (BMA) conference, that targets make her hospital a war zone. The minister
trotted out the government's usual defence: There have been too many targets, so fewer will be
better (where is the logic in that?) and the targets used to date have led to improvement. That is
just not so. Targets, by their nature, always damage performance. If you need to read the argument
more fully go to http://www.lean-service.com/9-9.asp
Mrs Hewitt is also on record as saying:
“But no organisation can cope with this top down, command and control approach for ever. We
have to move from reforms that depend upon tough performance management, to embedded
reforms that create a powerful, in-built dynamic for continuous improvement.'
I wonder if she is learning?
(Van guard News, July 2005)
The consequences of health policies
Dr Paul Miller, chairman of the BMA's consultants' committee says government policies could end
up harming patients' interests instead of improving services. His argument is that providing new
specialised treatment centres will destabilise the NHS.
Ministers seek economies of scale; they want to get the costs down. But in truth they are more
likely to put the costs up. Hospitals that used to provide the service will be forced to reduce their
capacity (cutting beds and staff). Patients that don't fit the specification, some because their case is
too complex, could find no provision left in the NHS. If there is no provision, they won't appear on
a waiting list. If there is a provision patients could be forced to travel anywhere in the country.
These are some of the knowable costs. Consider the long-term cost of the impact on surgeon's
training and hospital research.
The minister's policy tampers with the system. It will become apparent if NHS managers took
measures of end-to-end time from first presenting to diagnosis and treatment (as time-series data),
and time-series data about outcome. The increases in variation that will thus be exposed will be
indicative of the extra costs of the policy. By designing against demand we would learn to provide
better services at lower costs. If only the minister knew.
(Van guard News, July 2005)
Ambulance service gets the wrong solution
We have just seen the publication of a new plan for ambulance services. I know it won't work. Of
course it has plausible and maybe necessary features, like sending out more limited resources, as
they clearly have learned something about demand (few calls require two experts in a fullyequipped ambulance). But any design created in a management factory will be subject to
fundamental flaws. Demand will vary by geography, population and so on, any specification or
rule book will render the system to be less able to absorb that variety. It maintains the
measurement of arrival time, mandating how this will be measured to remove inconsistencies is
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merely doing the wrong thing righter. We need to measure achievement of purpose. The intent is
good and needed; we should make sure the service actually solves peoples' problems by the most
efficient means. But the intervention (telling them) will ensure resistance, some of it justifiable.
The right answer is to liberate method amongst the ambulance personnel. That would first require
the right measures. And that would first require that the minister learn something.
And then there would be fewer jobs in the management factory.
(Van guard News, July 2005)
Ministers interfere with scanning
To deal with the long waiting lists for diagnostic scanning the health minister struck a deal with a
private-sector provider. The result has been a catastrophe. We now read in the newspapers that
some patients are waiting longer, there are delays in reporting scans, the Royal College of
Radiologists has advised radiologists to check scans carried out by the private contractor as there
have been errors, patients are travelling long distances to be scanned, often being told to go home
as paperwork is missing and NHS scanning equipment stands idle.
It is a lesson in tampering, to use Deming's description. By focusing on transaction cost and scale,
they sub-optimised the system. If they had known instead how to focus on demand, value and
flow, they could have first optimised the NHS scanning system and would have had genuine
knowledge about what further requirements would need to be designed and where.
It is time ministers got out of management. They tell us they were dealing with 'blockages in the
system' but what they did was make the system worse, driving up costs and worsening service
provision, just as they have with every service I have studied in the public sector.
And, by the way, the ex minister of health, Alan Milburn, is reported as being a £30,000-a-year
consultant for the parent company of the scanning provider.
(Van guard News, May 2005)
Will new Labour save the NHS?
New Labour promised to save the NHS. Tony and co tell us they have invested resources, but does
investment equate to improvement? There may be more resources (nurses and doctors) in the
NHS, but what is happening to performance?
A reader writes:
“I emailed you earlier about a hospital trust which had had particular problems hitting the
government's target of 98% of patients passing through A&E in 4 hours, but in achieving
improvement had admitted c20% more patients to a hospital bed.
I recently saw the national figures and WAS SHOCKED. They show that in the last year (when the
target has increased from 90% to 98%), admissions into hospital via A&E have increased by 20%!!
The government are about to announce their 'success' in achieving these targets, and use this as
part of the election spin. Doubtless a couple of gongs will go to the bureaucrats at the centre who
have been credited with (bullying others into) this 'achievement'.
If targets are stupid, targets such as this are particularly stupid, as they are so far from end to end
regarding what is important to patients. The good honest hard working folk in the trusts have
done what most of us would have done if our jobs were threatened (as they regularly are) by
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failure to hit this target - anyone with a sprained ankle, bit of a cough or mild injury who has been
waiting over three hours in A&E gets pushed into a bed.
This bed costs c£300/ day in 'hotel' (i.e. nursing/ facility costs before any treatment), and deprives
patients of being at home, whilst exposing them to MRSA etc. Meanwhile, many NHS trust are in
meltdown financially, and costs are being cut in ways which seriously affect patients.”
It would be better for the patients, better for morale and cheaper to design the NHS against
demand, but they don't have any useful demand data. Why not? The minister insists they report
on lots of other wrong things. He should be held accountable for the consequential waste:
diminished health care, higher costs and de-moralised people.
(Vanguard News, January 2005)
Ministers push up costs of NHS
An NHS correspondent writes:
“In a nutshell, government set targets to get 98% of A&E attendees discharged or admitted within
4 hours – what happens - you've guessed it - rather than observe certain groups of medical patients
for 5-10 hours and then discharge them, they hit the target by admitting the patient to an expensive
bed (marginal cost >£200/day before drugs or any other treatment).
Dramatic growth in emergency admissions is being reported around the country, which is widely
attributed to the development by Trusts of a variety of forms of “assessment units”, which have
increased the number of patients identified as admitted during that period of assessment. This is
thought to be compounded by pressure on Trusts to speed up admission/discharge from A&E to
within four hours, leading to increases in the number of A&E attendees who are “admitted” to
hospital as emergencies for a short period of time.”
Add to this the costs of extra demand created by NHS Direct (see newsletters passim), the
estimated £30bn on a computer system that will fail, the costs of working to protocols… I could go
on.
(Vanguard News, December 2004)
NHS IT system costs up
It has been announced that the expected spend on the new NHS IT systems has risen from £6bn to
£30bn. Earlier this year I spoke on Radio 4 (In Business), they needed someone who would be
prepared to express doubts. In a nutshell I said: This is a scheme involving many computer
suppliers. They don't have reputations for co-operating with each other and they can be relied on
for behaving contractually, writing agreements that enable them to inflate the work; there is no
evidence that hospital consultants will allow access to their schedules for all and sundry; there is
no evidence that the lack of national access to patient records is damaging patient health care; there
is no evidence the designers of this system know anything about how the work works, and any
user will only use a new IT system if it helps them do the work better.
Costs up? Told you so. What would £30bn do if spent on health care?
(Vanguard News, November 2004)
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And government drives the human costs up
A reader writes:
“Re: Daily Telegraph October 18th Page 5 ' 'Politics' delays ambulance as leukaemia boy lies dying'
This sad story tells of a two hour delay for an ambulance for a desperately ill boy (who went on to
die later) with no ambulances available as the A&E department would not allow them to discharge
their patients as they were 'too busy'.
Something very similar happened to a colleague of mine whose wife collapsed one night. After a
20 minute delay she was picked up and taken to the hospital where my colleague was surprised to
find 4 ambulances parked outside also with their patients (as per the Daily Telegraph story). Being
an enquiring sort of chap, he asked why they were parked up outside and was told the reason was
that each patient had to be seen within 4 hours of arriving to hit targets BUT the patient was not
considered to have arrived until they were actually admitted into the hospital. Hence the hospital
had a reason to hold the ambulances outside until they had sufficient time to treat them.
Unbelievable but true.”
If only our health service were designed against demand. And don't assume that would mean an
increase in costs. In every other sector costs fall as service improves. We have found the same in
our first projects in health.
Someone should tell the minister.
(Vanguard News, November 2004)
The NHS don't want improvement
Two people I know have been interviewed for a top job at NHS Direct. One tells me he started
talking about the problems with their current measures and how changing the measures would
open the door on improvement and he was sent away with feedback to the effect he was odd and
likely to ruffle feathers. The other tells me their pre-occupation was to improve the expert decisionmaking software so they could further 'dumb down' the jobs. If only they knew….
If you missed the stuff on NHS Direct, how it increases demand, adds to health costs, demoralises
workers and does not solve patient problems, see past newsletters at: http://www.leanservice.com/6-news-0.asp
(Vanguard News, October 2004)
A and E demand grows, but why?
Demand into accident and emergency in Oxford has grown and is putting a strain on resources.
NHS managers are saying it is not because of the new out-of-hours general practitioner service.
But how do they know? What does account for the rise? Is this really a rise or is it common cause
variation? No one knows. Nothing new there then.
(Vanguard News, October 2004)
Waste money while doing nothing for our health
In the March Newsletter (again, you can read it at: http://www.lean-service.com/6-news-0.asp) I
included a piece from a fellow systems thinker about NHS 24, essentially saying it creates demand
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and does not solve patients' problems. My correspondent writes again:
“NHS 24 is a nurse led service. It's the first step along a journey that will eventually replace GPs
doing out of hours work with a telephone help line. The government want it that way because it's
'cheaper' than paying doctors to do out of hours work - now, just hold that thought because I'll
come back to it later. Having a nurse led service means that highly qualified and highly paid
nurses man the phones and give advice. Now, we already know that they don't use their expertise
because they use a technology based diagnostic tool - what a dumb thing to do and what a waste
of money and talent!
I'll give you an example of something dumb that happens with computer diagnostics in medicine.
The patient calls and says, 'I'm phoning you because I've had a headache for 3 days and it doesn't
seem to be getting better'. What would you ask? What matters to this patient? Does this demand
give you any idea what their headache is like? No, of course not! A GP would ask open ended
questions like, 'Tell me about your headache?' 'How did it start?' 'Where did it start?' 'Where is it
concentrated now?' 'Has anything happened to you in the last three days?' Questions like these
allow a GP to make a well informed and educated diagnosis - more often than not, the right
diagnosis.
What happens when you phone NHS 24 with this demand? The nurse looks up his/her diagnostic
tool and the first question they're told to ask the patient is, 'Did your headache come on like a clap
of thunder?' This indicates severe brain haemorrhage. Now the chances are that if the patient had
suffered a severe brain haemorrhage 3 days ago, they'd be dead – but common sense doesn't
prevail. The patient thinks about the question and predictably says, 'Come to think of it, yes it did'.
The nurse then sends an ambulance sprinting to the patient for nothing more than a simple
headache.
Computer diagnostics don't work when the root causes of a patient phoning are so varied. They
don't let your system absorb variety because they standardise the response AND don't use the skill
and expertise of the people using them. As a consequence, the ambulance service is now
complaining to NHS 24 that they're being sent to far too many non-emergency calls.
This of course is all waste - very expensive waste! Now, who do you think the NHS 24 managers
are coming down hard on - you guessed it, the poor nurses manning the phones and using this
dumb tool. The nurses know that it's rubbish but no-one listens.
Coming back to my first point about this all being 'cheaper'. The new GP contract has discouraged
them from performing out of hours – they've basically been told, 'We won't pay you for it'. Who
are the best people to do it? The GPs of course! GPs are now saying that they don't want to do it even when everyone knows its the best thing for their patients.
Patients who have chronic illnesses and rely on their doctors (the people who know them well and
help manage their conditions) are very, very frightened indeed.
Why would you do that to the people who voted you into office?
Anyway, out of hours services have, more often than not, moved to the A&E departments of
hospitals. Hospital managers are having chronic problems trying to staff these clinics - adding to
their work and adding to their waste. As a consequence, hospital managers recruit locums to do
the work. Who are the locums, the very GPs who the government have discouraged from doing
out of hours work in the first place. Here's the clincher, locums cost more money!
Now, I have no idea why anyone would think that this is a good way to run a business!”
(Vanguard News, September 2004)
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I'm glad I didn't go to the NHS
I was asked to meet a client's board and so had to withdraw at short notice from an NHS event; I
sent Wilma Paxton-Doherty instead; in truth a better person to attend, as she has both Vanguard
and NHS knowledge. But I am so glad I didn't go.
The audience was made up of those who had been deemed to have 'failed' by government's
current assessments. Those in power, who had wrought damage throughout the public sector via
terrible prescriptions and methods, spent the day telling those who had 'failed' what they needed
to do. Questions about the validity of their prescriptions were simply closed down. I would have
blown my top. The current regime holds the wrong people accountable. Election time is coming; it
is our opportunity to show who we think is accountable.
Wilma was so devastated by what she experienced she wrote notes about it.
(Vanguard News, August 2004)
Another way to cheat our health
In the last newsletter I included a piece written by a doctor on how people cheat to make the
targets in the health sector, in response a reader writes:
“There is another way that they fudge the waiting list. In Ysbyty Glan Clwyd (Hospital in Wales),
they send out letters each month to patients waiting for an appointment to tell them that they will
soon be going onto the waiting list and ask them to fill a form in saying that they still want the
appointment. It is only when they give out the appointment the time starts ticking down so my
friend has been on the 'waiting for appointment' list for five months and when he eventually gets
an appointment he will only be on the official appointment list for less than 6 weeks. His doctor
sent him to that hospital because they only have a 6 week waiting list when our closest hospital
has a waiting list of 10 weeks.”
(Van guard News, July 2004)
Will IT work in health?
The UK government is spending £6 billion on a new computer system that will have all patient
records on and enable appointment making. Will it work?
They have four problems:
●
Will the many IT 'partners' work together? IT companies are notorious for writing contracts
that earn them more money when things go wrong.
●
Will the system work? Anyone will tell you how difficult it is to keep customer records up
to date.
●
Will the people use it? When do records help health personnel do a better job? Did the
work start with this question or will health staff find the new system cumbersome in the
execution of their tasks? Will consultants allow access to their diaries? Anyone who has
worked with electronic diary management will know of the problems.
●
Will it improve health care? The answer to this is almost certainly no, because the 'solution'
did not start by questioning the way health care works. Like all public services it is full of
waste and has a damaging and large management factory.
Less than 16% of complex IT projects succeed. Why should we believe this one is going to work?
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We have found the only approach that gets value from IT is: Understand the work as a system;
improve without changing IT (except for taking it out); now 'pull' IT into the improved design. You
can predict how it will improve things. Now there's a difference! More about this in “Is IT bugging
you?” in the articles section of the web site.
(Vanguard News , June 2004)
Doctor reveals the truth
A doctor wrote in the Sunday Times:
“We … have a two-tier NHS. One is a virtual NHS of constantly improving statistics; the other is
the real NHS, where we cook the waiting times with elaborate trolley manoeuvres. The great
triumph of our managers has been to met targets often without cutting a single minute off the time
that our patients wait.”
He gives examples of how they have learned to 'cheat':
One of the key decisions in accident and emergency is whether to admit a patient or send him/her
home. Sometimes you cannot make this decision without a blood test. To avoid breaching the fourhour target, patients are admitted even when it is not necessary.
On waiting times for out patient appointments: “Our managers have discovered a beautiful way of
achieving a reduction of this waiting time. Instead of contacting patients and ascertaining when
they are available, appointments are simply assigned and put in the post. Subsequently, many of
these must be cancelled – but in the meantime the target has been met.”
He also describes how managers double-book slots in clinics, improving statistics but damaging
quality of care and the patient experience. And most disturbing of all he describes how people talk
about their 'escape plan'. The NHS is such a demoralising place to work that it drives people away.
Ministers believe target make people accountable. It is the ministers who should be held to
account.
(Vanguard News , June 2004)
Minister does the wrong thing righter
The UK's minister for health has halved the number of quangos (quasi-autonomous nongovernmental organisations) sitting above the health service. In my terms this means fewer
specifiers dictating what health service workers should do. He recognised the plethora of such
bodies was doing nothing for improvement.
But why didn't he close all of them?
We saw the same strange logic with targets: targets don't work so we'll have fewer of them. I think
we need to look into the ministerial mind. Any observations welcome.
(Vanguard News , June 2004)
The real causes of waste
A fellow systems thinker writes:
“During Jan, Feb and March I have been running a project involving two NHS Primary Care Trusts
and an Acute Trust (trusts are hospitals).
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The Department of Health has got 'targets' as an art form. The NHS execs and managers are like
rabbits caught in the headlights, micro managing everything to avoid losing a 'star' by missing a
target or 'cheating' to achieve a target. It has been a thoroughly depressing insight into how 5,000
good people work under duress in highly dysfunctional processes with hardly any grasp of the
system. Also, by setting PCTs in adversarial relationships with hospitals, and with GPs on the path
of avarice it is quite difficult for anyone to stand above it all so they can work on the system and do
the right thing for patients (which also achieves lower cost). Inside hospitals Clinician Consultants
hold management to ransom and are a particularly large cause of rework and waste through their
denial that their behaviours cause problems for everyone else.
Patient Choice, Payment-by-Results, Agenda for Change and so forth are all scams on good people
and attempts to get command and control through devious routes. It's so much enormous
unnecessary cost.”
And these interventions have had disastrous unintended consequences. The spirit of the
'accountability' regime, we should hold Tony et al accountable.
(Van guard News, May 2004)
Another example of designing waste in
The government plans to introduce a national tariff for operations and procedures carried out on
patients in the NHS, it means hospitals will be paid the same amount for each type of procedure. It
is a classic example of how to drive up costs while the intent is to manage (and reduce) costs.
Any intervention that inhibits a system's ability to absorb variety drives up costs. For a proof of
this read my latest book. (Finally a plug for the book!).
(Van guard News, May 2004)
NHS Direct
A reader writes:
“My brother in law is a General Practitioner. He says that NHS Direct is set up by people who have
no idea what they are doing - so where's the surprise? Apparently the service is staffed mostly by
nurses (very highly qualified nurses!) who are paid better than their colleagues engaged in direct
patient care in hospitals and GP practices - the government has to offer better money to lure them
away from the job they should REALLY be doing. That's the first mad bit!
The nurses typically deal with 12 to 14 patients over the phone in a 7 or 8 hour shift – yes only 12
to 14. That's 35 minutes per call which sounds OK, doesn't it? At least they could take their time to
find out what's really wrong and do something of some use! But (this is the second mad bit) they
use a computerised diagnostic tool which has so many safety nets built into it that three things
happen (typically):
1. Calls don't take that long
2. Nurses don't use their expertise (a huge waste when you consider that it could/should
be put to better use in direct patient care) and are told by the computer to a) send them to a
pharmacist, b) refer to the GP or c) get them to go to Accident and Emergency. Which
option do you think no one uses? You guessed it, a). People are scared to make any kind of
mistake so they use the safety nets - why wouldn't they?
3. Callers are mostly told that everything should be OK but you'd better check with your
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GP
As a consequence, (here's the third mad bit), GP practices are being clogged up with patients who
have nothing really wrong with them but are told to go to their GP by NHS Direct. My brother in
law has seen his waiting room filling up more and more and waiting times for appointments at his
practice becoming longer and longer since the service (?) was introduced. He regularly sees
patients who say that they have talked to NHS Direct and they don't know what's really wrong
with them, if anything at all. The GPs in his practice (and those he knows in the region) are getting
a bit hacked off with it! But they have no way to do anything about it. Now that's progress!”
The man running NHS Direct is now on the conference circuit doing a show on how good it all is.
If you see the show ask him what he knows about demand – why people call – and outcome –
whether and how effectively they get their problem solved. I have been amazed to learn the NHS
knows nothing about demand and outcome; it is no wonder the system is not improving.
Just like command and control managers running call centres in the private sector this man can tell
you all about the volumes of calls he takes, how long they take to be handled and so on, but he can
tell you nothing about the things you need to know about to improve the system. If he did he
would see the folly of using computer-aided decision-making. It wouldn't matter so much if it
wasn't our money he is spending and our problems he is not solving.
(Vanguard News, March 2004)
NHS 'Direct'?
A reader writes:
“In bed last night, I was nearly asleep and felt something touch my hair. I moved my hand to
figure out was it was and felt a very sharp pain. Suddenly, I was no longer nearly asleep. I
switched the light on and looked around the pillows because I thought I had a splinter in my hand.
I couldn't understand how I could get a splinter from a pillow. Then I put my glasses on and, as I
did this, saw a wasp on the carpet near the bed. After the wasp was safely out of the bedroom
window, and as I was on my own and have reacted badly to insect bites and stings in the past, I
called NHS Direct. After two handovers, duplication, validation (which is not what you need at
11pm when you're tired and in pain), over-specification and delay whilst I waited for a third
person with medical expertise to call me back, I spoke to Cheryl, who was very helpful and talked
to me for ages to find out what happened, what symptoms I had, medical history, treatments that
I'm allergic to etc. So, value created at the point of transaction, nil, because I had to go through all
that crap before I could talk to Cheryl, but very happy once she called me back. Cheryl told me
what to do to reduce the swelling and redness and when we finished the call and I'd done what
she suggested, I fell asleep reassured that everything was OK. This morning, when I was on the
train to Leeds, I noticed this:
'NHS Direct takes its time'
Resolute nurses are insisting on giving NHS Direct callers the time they believe they deserve,
reports Nursing Times (September 10).
A survey from King's College London says that while there is no official rationing policy regarding
the time NHS nurses spend on the phone, pressure nonetheless exists.
Callers gave NHS Direct the thumbs-up for its 'user-friendly' approach and the time allocated to
their queries. [...]'.
Hmmm. Time allocated to queries - yes, but 'user-friendly' approach – I don't think so!”
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Maybe they should call it 'NHS indirect'? Or 'NHS eventually'?
(Vanguard News, October 2003)
A visit to the Modernisation Agency
I was invited to take a look at what was going on in the NHS Modernisation Agency. I spent two
days at a 'learning workshop'. It is an ambitious intervention, bringing together groups of people
in like disciplines from all across the NHS to hear about good things, share what they are doing
and so on. I was impressed. There were numerous good examples of service re-design. Sadly they
are not supported by the system. In particular there are major issues with roles and measures.
People do what they do despite the system. They should be applauded.
Disquiet about targets is not encouraged, they are taken as a given. On day two when Professor Sir
George Alberti was in the hot seat, the targets issue came to the surface. Well-reasoned objections
from the floor were greeted with: “You can have all the flexibility you need, provided you make
the targets”. I was saddened to witness someone knowledgeable and wise in his own field make
such an ignorant and unthinking statement. I left. I'm going to send him a copy of my book
(“Freedom from Command and Control”).
People in the NHS are crying out for good leadership. They are not getting it from the incumbents.
(Vanguard News, October 2003)
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