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The public social welfare and health care sector is stretched for resources. Services of increasingly high quality are expected to be produced for customers with lower costs and by fewer hands. Pressures to cut costs and to rationalise operations have been sought to be met by developing management, among other things. Lean thinking has proven to be a key tool in all of this.

Lean found its way into the Finnish social welfare and health care sector in the early 2000s. Today, nearly 70% of hospitals have used or are using lean approaches, and many of Finland’s social welfare processes have also been “leaned”. Some experts in the field see lean as a philosophy that forces people to think about why they do a particular task, why an organisation exists, and how it can generate good things around it.

“Asking these questions on a daily basis is assumed to enhance productivity and efficiency. On the other hand, the lean approach also seeks to enhance efficiency by clocking times it takes to fetch certain supplies and by standardising different routes people use,” Professor Eeva Jokinen says.

Added value promised by lean is difficult to measure

But how has an approach originally created for industrial needs found its way into the human oriented social welfare and health care sector? An answer to this question can be sought in new public management, which has taken various fields of the public sector by storm. The welfare state’s “stagnated” models have been reformed with the business sector's dynamic lessons in mind.

Lean promises to produce more with less resources. When salaries, materials and other production costs have been cut to the bare minimum, the solution is to enhance productivity by creating a better customer experience. Added value is generated when a customer is willing to pay more for a service or a product.

“This equation works when we are producing cars or tourism services, for example. But when we move to the public sector, added value becomes harder to measure. And this is especially true for social welfare and health care services, where it is impossible to anticipate and standardise everything,” Jokinen says.

In the social welfare sector, service chains tend to be so long that streamlining them with lean thinking in mind is difficult. There are so many different actors and intersections where various service chains meet that making one process lean can result in bottlenecks down the chain.

“A hospital is a more closed system, and lean thinking is easier to apply there. In the social welfare and health care sector, successfully adopted lean processes can be found in hospitals where it is easier to manage the flow of patients and service chains,” Senior Lecturer Helena Hirvonen says.

Lean is only seemingly value-neutral

The LeanWorkGender research project led by Eeva Jokinen examines the lean production model and its implications on social welfare and health care services in the public sector. One aspect where critical thinking is needed pertains to equality.

“Lean is seemingly value-neutral and doesn’t take a stand on gender, race or class,” Hirvonen says.

The care sector, however, is predominantly female and much of the sector’s work is traditionally seen as female work: cooking, cleaning and care. Although “going lean” involves plenty of engineer-like calculation, scaling and measuring, the approach emphasises the ability for social and empathetic management, which is characteristic of female work.

“The ability to listen and to be empathetic is valued, but are people rewarded for it as a professional skill in the social welfare and health care sector? Even during this COVID-19 pandemic, health care workers have been recognised for their efforts, but nothing has been done about their pay.”

Lean also easily sidesteps, challenges and questions hospitals’ professional hierarchies. Professionals interviewed for the study highlighted regulated health care professions and their different obligations, as well as silo mentality in professions and management, as a challenge for lean thinking.

“Different studies have found that physicians are often a bottleneck in adopting lean practices, because they are not used to having to negotiate with others. However, lean thinking can also be an opportunity to tear down structures that do not make sense from the viewpoint of gender equality, for example,” Jokinen says.

Lean includes an idea of multi-professionalism and low hierarchies. This sits well with the reform of Finland’s social welfare and health care system, which is rooted in multi-professional collaboration for the benefit of the customer.

“Lean offers tools for multi-professional collaboration,” Hirvonen says.

Service design: new lean for the social welfare and health care sector?

Lean has been introduced to the social welfare and health care sector mainly under the lead of consultants. Indeed, consultant-led development has gained major footing in the public sector over the past decades, and large sums of money are invested in it.  Researchers, however, are worried that the public sector is relying on consultants without asking too many questions.

“Already now, Finnish health care is produced effectively by highly skilled professionals and with small pay. Yet, these professionals are not trusted with organising their own work. Instead, new businesses are constantly being built around enhancing efficiency, and money is also being spent there,” Hirvonen points out.

A mere belief in an endless possibility to develop management is not enough in a situation where human resources are already stretched thin, as is the case in elderly care, among other places.

According to Jokinen, the public sector could set an example and cut itself loose from the logic of the market economy that encourages us to buy more and more.

“A new approach could be found, for example, in the local economy or in the community economy.”

Lean is still at the height of its popularity, but has it come to the social welfare and health care sector to stay? At least for the time being, Hirvonen estimates. The logic of consultancy business is to develop something new to replace something old.

“Right now, people talk about service design a lot, and about how customers experience services,” Jokinen says.