Lean Thinking

Developed from the Toyota Production System, Lean Thinking has been applied to many sectors, including health, all over the world. It improves the quality of care and safety and removes delays in the user pathway whilst using no more resources. The mantra is right place, right time, right amount. Right first time, every time! Toyota emphasises the importance of staff involvement in service redesign:

People + Brilliant processes = Amazing results

Linked is the concept of Six Sigma. Six Sigma uses statistical tools to eliminate defects and reduce variation in processes- it is the ‘fine tuning’ in service redesign. Together, Lean and Six Sigma are powerful tools improving the patient experience.

Lean focuses on improving the whole process, not just parts. It focuses on problems, solving them and ‘learning by doing’ and on adding value–which actions add value, which are waste? The 5 key areas are:

  • How to improve flow to eliminate waste and reduce delays
  • How to get things right first time, thus improving quality and lowering costs
  • How to empower staff and motivate them to sustain results
  • To make good decisions using evidence
  • That learning by doing gets results, quickly.

The NHS Institute for Innovation and Improvement sees 3 things as core to Lean Thinking in the NHS:

  • Value
  • Smooth flow
  • Pull resources


Value is defined by and for the young person and their family -anything that improves their health, well-being and experience. This requires you identify the ‘value stream’ in their journey. This value stream is the key set of actions required to deliver value for young people. The Institute says only 5% of NHS activities is value adding – the trick is to maximise the value-adding steps and eliminate the unnecessary waste.

Some waste comes from unnecessary processes. Does that activity really add value? Are things duplicated- such as repeatedly asking the family to give a history that is already known from the referral letter or background information? Batching falls into this category- a common CAMHS example is attending to referrals at a whole team weekly meeting instead of daily attention by a sub-team or pair. Batching only adds delay for the user.

Do more specialist assessments add value? What do young people and families want that adds value and addresses their concerns?

Smooth flow

Designing process that work efficiently and quickly is surprisingly hard to do. Much of the time processes evolve through accident or custom and practice. When we say why are things done in a certain way, the answer is often, ‘because it has always been done that way’.

Flow will be smoothed by making sure the resources and ‘stock’ of any process are in the right place, that the information needed for clinical care and decision making is available and appropriate and that staff have the right and flexible skills at each step.

Pull don’t push

Adding value means providing capacity for the specific demand. A pull system is when the resources are ‘pulled’ towards the task as and when it is needed and not before or after. This means that lean services need a range of flexibly available skills that can be pulled towards the young person and family to help with their goals/health care needs.

In contrast, a push system is fitting the user into the resources provided. This may not suit the their exact needs. A push system is more about organising the system and not meeting the flexible needs of the young person and family. An old fashioned example is all patients being booked at the same time for outpatients so that ‘the doctor doesn’t have to wait’.

Lean and CAPA

As you can see from the above principles, CAPA is a lean system (especially when you include the full 7 HELPFUL Habits). It has a key focus on adding value to the user and working with their informed choice. Processes are smoothed by having full booking to both Choice and Partnership, a range of flexible core appointments and clinical specialisms to compliment. Individual and team job planning clarifies what activity is possible and where. Finally, the full booking to Choice and the selection of a clinician in Core work with the skills to meet their goals are clearly part of a pull system.

Want more?


NHS Institute for Innovation and Improvement (2007) Going Lean in the NHS. How lean thinking will enable the NHS to get more out of the same resources.

Available from institute@prolog.uk.com