The response to my blog on Deming has been interesting, both on and off-line. Over the past few blogs I have challenged the underlying principles of our healthcare delivery in training, culture and perspective. We train doctors and other health professionals for the 20th not the 21st century. We do not have an understanding of systems thinking. And, as Simon Dodds pointed out in his response to the blog on Deming, there is no real management theory in the NHS – just chaos. So here is a pointer in this regard.

I was fortunate to be a Health Foundation Quality Improvement Fellow at the IHI in Boston where I met Eugene Litvak, one of the leading proponents of managing operations in healthcare. When I met Eugene I realised that the solution to the issues we face could be solved by changing the business model and applying managing operations theory.

It is true to say that the NHS is ‘mismanaged’ and needs reform; this is the mantra of our politicians. Unfortunately the reforms proposed by our politicians are simply a reflection of the ideology of the day. They have failed to understand the need for a different business model and theory. Until there is this radical change (only radical in healthcare, routine elsewhere) the underlying problem will remain: the lack of a credible theory to address the major issue of variation in the way healthcare is delivered.

Deming said that if there is only one thing to address, it should be the elimination of variation. But is the problem wider than that? One needs a management theory to achieve this.

I have often said that the improvement movement is not going to change much in the long-term unless there is a fundamental rethink of the model of care and the business model behind it. There is simply little theory behind what healthcare mangers (both clinical and non clinical) do. They live on intuition and crisis management. It is amazing how the politicians think that by shifting commissioning and altering the payment system, more efficiency will emerge. This shows how misguided the current reforms are. Just as there is no system thinking, there is no management theory of note.

And now to managing operations theory. When I was in Boston Eugene Litvak demonstrated to me the way we could decrease cost and increase safety at the same time. For those who wish to see the light, look at his website The application of managing operations theory, which is standard in other industries but rare in healthcare, is one of the keys to the conundrum we are in. Managers and clinicians in healthcare have missed the point. They do not know improvement science or change theories and they do not appear to have a management theory.

Am I being too harsh? Well, consider the major problem that we face – that of variation. Litvak and his team have worked in the UK with me and they clearly demonstrated that the major problem in healthcare is variation – all artificial, created in the way we have designed healthcare around the vested interests of providers and not the needs of patients. Artificial variation needs to be eliminated and not kept because we cannot challenge those who refuse to change. Natural variation is what the patient brings and this needs to be managed – and managing operations offers many tools to do this, e.g. queuing theory.

Right now our system is full of unneeded variation. The results from places that have implemented the approach advocated by Litvak have been phenomenal.

Adoption of this approach would go a long way to decreasing the deficit in healthcare funding. Unfortunately the medicine is bitter – for managers the need to jettison the intuitive crisis management, and for clinicians to lose their autonomy on how services are organised. Not many CEOs or even Health Secretaries are willing to go on that journey. But read the case studies and one will soon realise the benefits to be gained.

Yet I cannot place the responsibility for this on poor health management. Rather it is both the management deficiency and the vested interests of the medical profession, represented by the union and colleges, which has created this impossible situation. What is required is a fundamental re-examination, and then redesign, of how we deliver healthcare.

Peter is a Consultant Paediatrician at Great Ormond Street Hospital and The Royal Free Hospital, and is a Health Foundation Quality Improvement Fellow.

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