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Last Updated: Wednesday, 14 June 2006, 11:00 GMT 12:00 UK
Making the NHS into a lean machine
By Nick Triggle
Health reporter, BBC News

Productivity is now the buzz word in the NHS.

With the health service facing a 512m deficit in England, pressure is growing on number crunchers to save money.

But could a practice developed by car manufacturers Toyota nearly 60 years ago hold the answer to the NHS's problems?

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Lean has proved popular in the car industry

The Lean philosophy was developed by Toyota in the 1950s and 1960s to improve the efficiency of car production.

It was used to ensure the 10,000 components of a car were ready at the right time of the production line to allow the fastest possible production of motor vehicles.

Lean encourages managers to look at how customers and goods flow through their systems to unlock bottlenecks and inefficiencies.

In doing so it defines value-adding activity solely as those which affect the customer and estimates 90% of all actions within organisations are wasted because they add no value.

The principles have been adopted by organisations as diverse as Tesco and the Royal Navy and now NHS chief believe it could help the NHS out of its financial quagmire.

Unsurprisingly, for a concept developed by the car industry, supporters like to use an analogy of how traffic flows on roads to illustrate how it could benefit the NHS.

In a report by the Lean Enterprise Academy UK, a think-tank set up to promote the technique, the authors suggest readers imagine a two-lane road capable of taking 1,000 vehicles an hour.


It warns jams could occur if slow-moving lorries are allowed to travel in both lanes, blocking the movement of faster cars.

The report said a similar effect can be seen in A&E departments where patients are assessed and placed in a waiting list according to priority.

Instead, it said A&E patients should be divided into two categories - those that need to be admitted into hospital with serious injuries or condition, who should be seen on a priority basis, and those that just need patching up and can be seen on a first come, first serve basis.

The method was adopted by Flinders Medical Centre in Adelaide, Australia, two years ago and saw average waiting times fall by 25%.

We know that our case for extra finding will fall on deaf ears unless we cut out waste in the system
Gill Morgan, of the NHS Confederation

Professor David Ben-Tovim, the officer in charge of redesigning care at the Adelaide centre, said it had transformed the way care was provided after coming close to meltdown.

"Before, our emergency department was so congested it was an unsafe place to be."

Lean has also proved successful in the UK, the report said.

The Royal Bolton Hospital has used it to redesign its pathology department. Looking at how blood samples were tested it realised the process was being unnecessarily slowed down.

Journeys were being made across the hospital because equipment was located in different rooms and there were delays taking blood samples for testing because staff waited until they had a batch of samples before sending them off.

The hospital took simple measures, such as moving equipment, knocking rooms together and analysing samples as they come in.


The changes have meant that the time taken to process blood samples was cut from 24 hours to three.

Hospital chief executive David Fillingham said: "When we started out, some people were very sceptical. But I've never seen anything that energises staff in this way."

Daniel Jones, chairman of the academy and report author, said if Lean principles are to be adopted by the NHS across the board, it needs to alter the way it looks at care.

"The problem is that the NHS looks at the patient / doctor interaction when it is designing services.

Image of an operation
The NHS is looking to become more efficient

"But really it is a whole series of different departments and what is important is the interaction between the departments as the patient goes through the system. That is what we are trying to address."

The NHS Confederation, which represents health service managers, has been so impressed with the techniques that it believes if could be a possible solution to the deficits problem.

Chief executive Gill Morgan said: "We know that our case for extra finding will fall on deaf ears unless we cut out waste in the system.

"Lean works because it is based on doctors, nurses and other staff leading the process and telling us what adds value and what doesn't."

But others remain more sceptical.

John Appleby, chief economist at the King's Fund health think-tank, said the NHS was certainly inefficient in places, but the challenge was addressing that in what is a complicated system.

"Care could be designed better, but quite often change requires time and money which isn't always available.

"The second issue is how you define productivity. If it is patients treated per pound spent, then you ignore potentially important aspects of health care such as spending time with a doctor discussing your health.

"Health care is such a complicated system that you cannot compare it to car factories."

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