Tomorrow's NHS productivity initiatives need to avoid today's mistakes

NHS productivity initiatives have a pedigree going back decades. While the more recent focus has been on “lean”, little long-term benefit has been gained.

The reason why concepts to improve productivity have generally failed to achieve more than a local approach can be seen when we consider the four most commonly initiated types of programme:

• Limited scope. Focused on a single department or area without reference to upstream or downstream activities. Gains tend to be short-lived with little impact on the overall pathway;
• Report based. Involves an extensive research and planning phase that produces an excess of data which is often not implemented;
• Disjointed multi-agency. Initiated by a lead organisation with partners having variable levels of commitment. Normally stalls because of the politics involved in making changes to budgets and structures;
• Commissioning led productivity. Focusing on patient pathways from end to end, this should be the most effective approach but mismatches in contractual cycles. Focus on organisations rather than pathways and the problems of dealing with large provider organisations normally results in relatively small scale productivity gains. 

The lack of proactive senior sponsorship means that when a productivity programme starts to go wrong it is often the person tasked with leading the lean programme who is caught in the crossfire, while individual clinicians and managers who have avoided being involved or even actively worked to undermine it experience no overall penalty.

Both types of behaviour create a downward spiral with fewer people wanting to get involved and an even greater incentive for those who perceive they are already too busy simply to opt out.

The financial situation gives us the perfect opportunity to turn this around if the will exists. The biggest gains will come from working across organisational boundaries and tackling head on the contentious issues of shrinking spheres of influence, closing facilities and transferring resources.

The most successful senior managers will be those who have best improved productivity rather than those sitting on the biggest budgets.

There is also a practical need for a cadre of expertise to facilitate projects and a requirement on divisional and service level managers and clinical leads to give people time to contribute to the projects, taking the mindset of short-term pain for long-term gain.

In addition, mega (or micro) productivity programmes need to be replaced with flexible, medium scale (less than six month) analysis-light projects focused on rapid improvements in productivity and collaboration.

Perhaps the biggest issue is creating awareness and capability across health and social care economies.

Senior leaders who want their programme to take hold should aim for at least 0.3 per cent of the total workforce allocated to service improvement activities full-time, 3 per cent capable of initiating projects, 20 per cent or more having been involved in a productivity project within three years and more than 90 per cent aware of the basic tools and concepts within 24 months. 

All of that will be undermined, however, if they fail to sponsor it effectively.

Case study

Hounslow & Richmond Community Healthcare has taken a flexible, pragmatic approach to improving productivity. HRCH was created in 2009 from the former provider arms for two very different London boroughs with diverse communities. As well as the difficult task of merging teams, HRCH has to manage differences in commissioning needs across the areas served.

To address this, the senior management team established the Working Smarter programme to bring together the various strands of improvement activity. This coordinated approach, along with proactive sponsorship by director of operations Jo Manley, reduced the risk of the programme fragmenting.

Jo and her colleagues recognised the need to avoid becoming bogged down in analysis and to focus on the rapid implementation of medium scale projects. A focus on underlying performance issues has produced impressive results.

For example, 95 per cent of all health visitor new birth visits are meant to occur within 14 days but initially this was only achieved in 19 per cent of cases. Between June and September 2010, lean concepts helped increase this to more than 60 per cent.

Similarly, the audiology and child development team have tackled issues preventing them from reliably achieving an 18-week pathway. A more consistent process for achieving the target has eliminated the need for bank staff and created sufficient capacity to enable core staff to cover absences without falling behind.

Jo Manley says: “We recognised early on that we would need to make some substantial changes in a diverse range of areas and that we weren’t going to achieve what had to be done by producing endless reports or trying to tackle the largest projects in a single swoop. Engaging our front-line service managers and teams in helping us to improve the way we do things was the key to success and this has really paid off.

“We recognise that the problems are ours and the solutions are too and have drawn in the expertise from Amnis to help us accelerate projects and support us in key areas.”