The contract between the NHS Trust Development Authority and the Virginia Mason Institute is good in theory but could very easily backfire. Jim Mather sets out what needs to be considered

Last month the TDA announced the letting of a new contract between it and the Virginia Mason Institute.

In doing so it said: “Five NHS trusts are set to benefit from the influence of internationally acclaimed healthcare experts as part of a new initiative launched by health secretary Jeremy Hunt and the NHS Trust Development Authority.”

Jim Mather

Jim Mather

And that “staff from the Virginia Mason Institute will spend time in the five trusts over the course of the next five years helping the doctors, nurses and leaders figure out how they can improve using the tools developed in Seattle”.

“The programme will run over five years and set five NHS trusts on the road to becoming leading healthcare institutions, at the same time sharing learning and benefitting the NHS as a whole.”

Welcome or not?

Personally, when I heard this, part of me welcomed the experimental nature of this move and the use of expertise from elsewhere.

But part of me also worried that this move could backfire. My reasons for feeling so concerned were as follows:

  • The justified antipathy I saw for “lean” (an approach to improve flow and eliminate waste, developed by Toyota) on the part of the trade unions during my chairmanship of the Working Together Review for the Scottish government last year.
  • A recent book, The Whitehall Effect, and a specific paper on the dangers of lean, An Exploration into the Failure of Lean, both written by John Seddon of Vanguard Consulting.
  • My concerns that this approach would not address many of the points raised in a report from the Academy of Medical Royal Colleges and Faculties in Scotland in May.
  • My perennial concern that Virginia Mason’s home nation, America, has managed to sacrifice many of the wholesome ideas, from important sources such as Adam Smith, Frederick Taylor and the Toyota Production System, on the altar of short term financial returns – with terrible unintended consequences.

Taking these points in turn:

1. Union antipathy

Academics like Philip Taylor at Strathclyde University have identified that the growth of forms of lean working has led, not to creative outcomes, but to re-engineering and micromanagement.

Professor Taylor has also identified other adverse effects, such as the negative impact on the health of staff from programmes that promote lean work and the intensification of the working environment.

It has also been noted that the move to lean has often been accompanied by a heavier emphasis on performance management, which often degenerates into misuse, and a further spiral of distrust and lack of fulfilment.

2. Seddon’s critique

Seddon is convinced that standardising work in a service organisation lessens the capability of the system to absorb variety and thus it can drive up costs.

It also reduces the quality of outcomes, staff morale and customer satisfaction, and hence risks a vicious circle that could end up in a dysfunctional mess.

‘Standardising work in a organisation could lessen the capability to absorb variety, driving up costs’

He believes that claims for lean improvements are therefore usually marginal - for example, minor process improvement are often illusory, and creating changes in activity costs that do not reflect an increase in the total cost.

In his conclusion, Seddon is adamant that Taiichi Ohno, the father of the Toyota production system, and hence the father of lean would be appalled at this movement, saying that: “Since its conception, lean has been destined to fail as a movement.”

 The lean protagonists did three things Ohno counselled against. They:

  • gave it a name,
  • codified method; and
  • set out to explain.

The movement has been successful in terms of revenue to the movement because its means of intervention fitted with management’s belief that change can be achieved with tools and projects.”

3. Recommendations on patient safety

The recent report by Alan Paterson, on behalf of the Academy of Medical Royal Colleges and Faculties in Scotland, was triggered by concerns in response to Mid Staffordshire, and has recommendations on patient safety that I doubt could be delivered by a focus on lean.

‘I don’t see how an emphasis on lean could create the conditions needed for a supportive environment’

I do not see how an emphasis on lean could create the conditions needed for “a supportive, listening environment [that] must be created to produce a culture which instils confidence in staff, patients and relatives and in which innovation is encouraged”.

Nor do I see how lean could completely provide the “action [that] needs to be taken by NHS boards to improve the working culture within the NHS and in particular to address the ‘learned helplessness’ which can be experienced by staff when poor standards of care are condoned and perpetuated due to a combination of organisational and external pressures and a sense that this cannot be changed at an individual level”.

And these are just two examples.

4. American short termism

As for America and its neoliberal tendency to monetise and financially engineer operations in favour of short termism, I rest my case, and worry for the future.

I hope I am wrong about this TDA/Virginia Mason intervention but I feel confident that the institute and the trusts in question could do well by listening to the unions and to Professor Seddon, taking their concerns to heart and testing their plans against the recommendations of the Academy of Medical Royal Colleges and Faculties in Scotland.

Jim Mather is the former chair of software company Gael and a visiting professor at Strathclyde and Heriot-Watt universities