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JMD
24,2

The impact of theory of

constraints (TOC) in an NHS trust

116

Ashridge Business School, Ashridge, Berkhamsted, UK

Guy Lubitsh
Christine Doyle
Received July 2003
Revised May 2004
Accepted May 2004

University of East London, Stratford Campus, Romford Road, London, UK

John Valentine
Royal Holloway University of London, Egham, Surrey, UK
Abstract
Purpose The study investigated the impact of theory of constraints (TOC), a change methodology
previously employed in the private sector and now adapted to the health sector, on three NHS Trust
departments, Neurosurgery, Eyes and ENT, especially in relation to reducing waiting lists in the
system and improving throughput of patients.
Design/methodology/approach Data were collected over a period of 40 months, on a number of
NHS performance indicators, before and after the TOC intervention. An interrupted time series design
with switching replications was used to investigate the impact of the intervention.
Findings An overall ARIMA analysis indicated that TOC had an impact in both Eyes and ENT.
Out of 18 measures, 16 went in the direction of the hypotheses, the probability of these changes in the
predicted direction by chance alone was 0.0006. However, there was a lack of significant improvements
in neurosurgery that was associated with the size of the system, complexity of treating neurological
disorder, heavy reliance on support services, impact of emergencies on elective work and the
motivation and receptiveness of staff to the proposed changes.
Practical implications In order for organisations to maximise the benefits of TOC organisations
should take into account the social environment in which they exist.
Originality/value The importance of customising the intervention to the local needs of each
department, and the requirements for leadership and robust project management are highlighted in
this study. Failure to do so can potentially derail the change process.
Keywords Organizational change, Business improvement, National Health Service, Problem solving
Paper type Research paper

1. Introduction
Goldratt (1984) proposed the theory of constraints (TOC) as a scientific process for
generic problem solving, particularly in manufacturing industries and it has
been developed over the past 20 years (Bradbury-Jacob and McClelleand, 2001;
Dettmer, 1997; Houle and Burton-Houle, 1998; Kendall, 1998; Mabin and Balderstone,
2000; Scheinkopf, 1999). Goldratt challenged a few key sacred cows in business.
For example, he argued that the focus of business was often on cost cutting when instead
Journal of Management Development
Vol. 24 No. 2, 2005
pp. 116-131
q Emerald Group Publishing Limited
0262-1711
DOI 10.1108/02621710510579482

This research was conducted under the auspices of Ashridge Business school and submitted in
partial fulfilment of the degree of Professional Doctorate in Occupational Psychology at the
University of East London.
The authors are grateful to Kate Loewenthal (Royal Holloway University of London) for her
useful comments on the final draft of this paper.

it should be on making a profit through increased throughput. He also claimed that the
focus of management was on measurement and rewards of local efficiency rather than
highlighting systems efficiency and its contribution to the ultimate goal. TOC was
developed in manufacturing and this context will be used to explain the theory.
Goldratt summarised the application of TOC to the operational environment as
having five key steps:
(1) Identify the constraint. Every system has a constraint/bottleneck. This is the
weakest link that limits the system in some way. The systems effectiveness is
defined by the rate of the weakest link, and these can vary from physical
bottlenecks such as machines or equipment that have the least capacity in the
system, or policy, or behavioural constraints and external constraints that are
outside the system.
(2) Get the most out of the constraint. There are several ways in which the
effectiveness and efficiency of the constraint can be maximised.
(3) Support the constraint through subordinating the non-constraints to
the constraint. In this step, the non-constraint machines (i.e. the vast majority
in the system) are subordinated to the constraint machine.
(4) Elevate the constraint. The first three steps mainly focus on changing the way
the constraint is used without spending money.
(5) Go back to step 1. Goldratt argued that TOC was an iterative process of
improvement. Introducing the steps described earlier usually means that
another point in the system becomes the constraint. Therefore, you need to
re-evaluate and hit the next constraint by going back to step 1.
Following the first three steps would allow for dramatic improvement in throughput,
without extra money/resources. This contradicts a common management assumption
that most improvement in performance requires extra money/resources. However, can
the TOC, a change methodology previously employed in the private sector, make an
impact in the NHS?
Reviewing the literature of TOC in the manufacturing sector supports a view that
TOC can be associated with an increase in productivity for both individuals
and organisations. In particular, TOC has simultaneously increased throughput and
reduced both operating expenses and inventory (Rand, 1984; Meleton, 1986; Chase et al.,
1998; Bushong and Talbott, 1999; Miller, 2000). However, the research is anecdotal and
fragmented, and has been focussed on the theoretical debate about the different
techniques rather than on robust qualitative or quantitative research methods.
Longitudinal studies are also rare and there are usually no control groups.
Additionally, research has been mainly focussed on the US manufacturing industry,
with little evidence for the application of TOC in UK healthcare systems.
Researchers such as Katok et al. (1986), Vollmann (1986), Massood (1998),
Tollington (1998) and Michalski (2000) examined the effectiveness of identifying and
exploiting the bottleneck. They reported the following benefits. One, by identifying the
bottleneck in advance you can reduce the variability through reducing the material
ordered into the system. Two, efforts specifically targeted at the buffers located
before a bottleneck ensure that material going through the bottleneck does not have to
be reworked. Three, scheduling the bottleneck resource results in better use of the

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bottleneck area. It was this area that paid the greatest dividends in terms of net profit.
Four, having a buffer before the constraint ensures that the bottleneck is less
vulnerable to random disturbances in workflow.
Knight (2001) argued that utilisation of the bottleneck in a health care setting
can impact overall productivity without compromising quality of care or making
staff work harder. He claimed that the bottleneck can be affected by the lack of
synchronisation of previous and subsequent stages in the chain. For example,
surgeons and theatre staff may not be able to operate because there are no beds
available since they have been filled with patients admitted unnecessarily early.
Research and case studies outside manufacturing are rare a Midwest US bank is
reported as having achieved significant reduction in processing times for mortgage
applications, following the application of TOC (Bramorski, 1997). Mabin et al. (2001)
report the use of TOC methods in overcoming resistance to change in a case study
involving a New Zealand bank merger. They argue that in the context of TOC
methodologies, resistance can be harnessed as a necessary and positive force. Rahman
(2002) used TOC thinking process methods (a mix of common sense, intuitive
knowledge and logic) to develop models of supply chain management with students
undertaking a masters degree in international logistics management. The research led
to the identification of elements of successful supply chain management but also
developed the causal relationships between these elements. TOC has not previously
been applied in healthcare settings but other approaches to change management have
been employed.
Researchers including Willcocks et al. (1997), Packwood et al. (1998) and
McNulty and Ferlie (1999) have examined the impact of change programmes
such as business process re-engineering (BPR) in a healthcare setting. Hammer and
Champy (1993) define BPR as reconceptualisation of business processes with a key
role for IT in the redesigned solutions. In many cases, this meant reducing several
of the chains in the system and therefore making it more efficient.
Willcocks et al. (1997) looked at the experience of the John Radcliffe Hospital where
BPR concepts were applied to the whole hospital following successful pilot work in two
specialities. Hospital work was described in process terms and the management
arrangements were changed to reflect these processes with a flatter structure based on
multi-disciplinary team working. Information technology was a key element in the
approach, given the inadequacies of the software system for the newly developed NHS
internal market. Both complexity of the information requirements and political nature
of the organisation led to an evolutionary, bottom up approach. Shortfalls in training
for staff, resource constraints and scepticism over the benefits of the IT systems were
observed but equally, the new process based structure was in place by 1993 and was
seen to be generally more efficient.
Packwood et al. (1998) looked at the experience at Kings Healthcare in London.
The trusts embarked on a BPR programme in 1993, a period when the trust
performance was deficient in a number of respects. The aim of the BPR programme
appeared to be delivering more modest, but tangible gains in performance and cost
saving, falling short of transformational change. Particular issues identified included:
the difficulty of moving away from hierarchical, functional groupings to a matrix type
of organisation and the difficulty of genuinely starting from a blank sheet of paper in
the redesign process, given the resource and political constraints in the NHS. This led

Packwood et al. to conclude that BPR, particularly in a public sector setting, needs to be
applied incrementally and selectively.
McNulty and Ferlie (1999), Packwood et al. (1998) and Willcocks et al. (1997) argued
that the approach to BPR had been evolutionary in nature, with much clinical practice
untouched by the organisational change programme. However, they also concluded
that BPR had been a catalyst for change within the Leicester Royal Infirmarry (LRI)
and the basic tools of process analysis and redesign had become enduring ideas within
the organisation. They identified that an incremental approach to change is more likely
to succeed within an organisation as complex as the NHS where managerial power is
limited by professional freedoms.
In contrast to major change interventions such as BPR, West, Borrill and colleagues
(Borrill et al., 2000; West et al., 2004) have been examining issues concerning the
management of employees in the NHS and their links to trust performance. They found
that HR practices such as the extent and sophistication of appraisal and training
systems for staff and the percentage of staff working in teams had a strong
relationship with patient mortality generally. In particular, the sophistication of the
appraisal system was associated with the equivalent of 1,090 fewer deaths per 100,000
age standardised admissions for hip fractures more than 1 per cent of admissions or
12.3 per cent of the mean number of deaths. Ongoing research is examining the links
between the level of staff involvement/participation in NHS organizations and their
performance (Borrill, 2004). Such issues are key to this study because the TOC
intervention was a highly participative process whereby teams of managers,
consultants, nurses and administrators joined together to identify constraints and
devise solutions to which all were committed.
The study here represents an advance on previous evaluation of Corporate Change
Programmes in a number of ways. First, the design of the study assessed the impact of
TOC before and after the intervention rather than simply claiming success. Secondly,
this study is longitudinal and therefore provides evidence about the sustained
long-term organizational change in the organisation. Thirdly, it was a pioneering work
evaluating the impact TOC in a healthcare setting. Finally, most TOC research to date
has been based in the USA. This study took place in the UK.
The study investigated the impact of TOC, a change methodology previously
employed in the private sector and now adapted to the health sector, on three NHS
Trust departments: Neurosurgery, Eyes and ENT. It particularly examined reduction
in waiting lists in the system and improving throughput of patients. For each of the
hypotheses below it was expected that improvements would be maintained over time
(i.e. the period of study). This is an important strength of this design since studies
have shown that the effects of organisational development (OD) interventions tend to
decay over time (Guzzo et al., 1985). Given that TOC is expected to increase efficiency
and throughput, the following changes were predicted to occur following the
intervention:
H1. Number of GP referrals/requests for first outpatients will have a sustained fall
following the introduction of TOC.
H2. The impact of TOC will increase the number of patients seen in the outpatients
department.
H3. Number of outpatients seen within 30 min will show an increase following the
introduction of TOC.

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H4. Cancellations of outpatient appointments by the hospital will show a

sustained fall following the introduction of TOC.
H5. Cancellations for outpatients by patients (Do Not Attend DNA) will have a
sustained fall following the introduction of TOC.
H6. Waiting times for theatre (i.e. patients waiting over 15 months and total
number of waiters) will have a sustained fall following the introduction of
TOC.
H7. Finished consultant episodes (FCE) (i.e. elective, non-elective, day cases) in
theatre will show an increase following the introduction of TOC.
2. Method
2.1 Research design
The researcher employed an interrupted time series design with switching replications
(Cook and Campbell, 1979) to investigate the impact of TOC on waiting times and
throughput in the system. Three different departments formed experimental groups in
the Radcliffe Infirmary (RI) at Oxford, these being neurosurgery, eyes and ENT. The
interventions were at different points in time. The researcher chose Southampton
hospital as a control site to the RI because the ENT department has a similar case mix
and it is also both a medical and teaching hospital. Furthermore, the RI and
Southampton also match in terms of size. ENT Southampton was not to have any TOC
intervention and was employed to provide non-equivalent control groups in order to
address any impact of other national changes in ENT departments across the UK, such
as a government initiative to provide extra money to ENT departments across the UK.
However, despite an initial agreement, the researcher did not get access to the
Southampton ENT data.
The researcher collected data for each department before and after the intervention.
The data available from the different departments were collected between October
1997 and January 2001, a period of 40 months. Table I shows the number of monthly
measurement points pre- and post-intervention.
A time series consists of multiple observations of the same variable over regular
intervals of time (e.g. monthly figures of waiting times for outpatients). The time
series quasi-experiment was proposed as a means of assessing whether
the intervention had an impact on a social process. If it did, we would expect the
observations after the treatment to be different from those before it. That is, the series
should show signs of an interruption at an expected point in time (Cook and
Campbell, 1979).
The effects between the pre- and post-regression lines would have to be continuous.
Cook distinguishes between continuous effects, which do not decay over time, and
discontinuous effects, which do not persist over time (Cook and Campbell, 1979).

Table I.
Monthly measure points
pre and post intervention
(October 1997-January
2001)

Department

Month of intervention

Eyes
Neurosurgery
ENT

October, 1998
April, 1999
February, 2000

Number of months
Before intervention
After intervention
12
18
28

28
22
12

The longitudinal design of the study lends itself to examining the long-term continuous
effects of the intervention.
As already mentioned, this is important since studies have shown that the effects of
OD interventions tend to decay over time (Guzzo et al., 1985).
2.2 Procedure
2.2.1 Participants. Three different departments formed experimental groups in the
hospital. These were neurosurgery, eyes and ENT. Each department received an
intervention that was a TOC workshop specifically for the department. The workshop
was an inclusive change process involving representatives from all groups in a
department from the outset. These were: nursing Director, operations Director,
consultants team; nurses; support staff; and representatives of support services (for
example, in ENT these included representatives from Audiology).
2.2.2 The workshop: TOC workshop for the RI. The change intervention was a
two-day workshop. Ashridge Consulting provided the support for the workshop.
The first day was about concepts of whole systems and TOC including Goldratts
five focussing steps mentioned earlier in the introduction. The second day was about
how to put the theoretical principles into practice. The workshop was highly
interactive, using a variety of teaching methods including computer simulation. It also
provided opportunities for participants to reflect creatively about their work practices
using the TOC framework. As part of the workshop, participants designed specific
action plans and appointed a project manager and a steering committee to monitor
progress.
For example, the initial implementation of TOC in ENT in this study, the key
bottleneck identified was the lack of nurses in the inpatient ward area. Early work was
to set-up a team that included consultants, nurses and management to examine
recruitment and retention in the ward area. What are the reasons for nurses leaving
the ward? How can we attract and retain more nurses? Further work was done
in relation to offloading some of their work using Health Care Assistants and
providing counselling and a staff support group where nurses can air some of their
difficulties.
Knight (2001) described some of the changes implemented in trusts after TOC
workshops. In many trusts, they realised that by simply managing and synchronizing
the activities that need to be accomplished before the bottleneck, their throughput of
patients increased. In a number of trusts, clinicians operating time was often the
limited resource. Although theatre utilisation can be as high as 95-100 per cent, a closer
examination often reveals that between 30 and 40 per cent of the time when theatre
staff are ready to work they have nothing to work on owing to a delay in the preceding
stages of the process. Addressing this issue alone had a dramatic impact on waiting
times and productivity in the system.
2.3 Measures: framework for evaluation of TOC
This study looks at the period from October 1997 to January 2001 (40 months) and
hence covers the period of the TOC work within neurosurgery, eyes and ENT (Table I).
In Figure 1, the major links in patient flow in the NHS and the evaluation indicators
at each step are presented. The evaluation measures were taken from each link in
the flow.

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Figure 1.
Major links in the patient
flow and evaluation
indicators

For example, in step 2 the patient visits outpatients. The number of patients that
were seen in outpatients each month by the various departments was the indicator for
evaluation. Another example is step 3 patient in theatre. This was evaluated by
looking at throughput indicators in theatre such as; FCE (i.e. the number of patients
seen in theatre). The researcher monitored and investigated other confounding factors
that might impact measures pre- and post-intervention including whether extra
resources or money were invested in the system during the period of the study.
There was a set of ten variables.
(1) GP referrals/requests to outpatients. This measure indicates the number of
requests/referrals that were made to outpatients each month by GPs.
(2) Outpatient throughput by month. The total number of patients who were seen
each month at the outpatient clinic.
(3) Outpatient appointments cancelled by hospital. This measure indicates the
number of outpatient appointments cancelled by the hospital: for example, if a
consultant cancelled a clinic.
(4) Outpatient appointments cancelled by patient. This measure indicates the
number of patients each month who did not arrive (DNA) for their outpatient
appointment.
(5) Outpatient seen within 30 min. This measure indicates the number of patients
who were seen in the outpatient clinic within 30 min of arrival.
(6) Waiting list for theatre over 15 months. The number of patients, by month, who
have been waiting for theatre/operation for more than 15 months.
(7) Total waiting list. The total number of patients each month who have been
waiting for theatre.
(8) FCE non-elective. The number of patients each month who underwent surgery
on coming through emergency or a transfer from another hospital.
(9) FCE day cases. The number of patients each month who underwent surgery
through routine theatre lists and did not stay overnight.
(10) FCE. The number of patients each month who underwent surgery through
routine theatre lists and stayed overnight.

2.4 Analysis
Conventional statistical procedures such as analysis of variance or multiple regression
are not usually suitable for analysing repeated observations over time because they
tend to violate the assumption that error will be independent (random) within and
across conditions. Since successive observations in a time series tend to have
systematic trends this assumption is rarely met (Hersen and Barlow, 1976). Cook and
Campbell (1979) recommend using the autoregressive moving average (ARIMA)
models to analyse an interrupted time series. The reason for using ARIMA for
intervention analysis is that it removes systematic trends of data, leaving random

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Figure 2.
Overall analysis of
ARIMA results on the
impact of TOC on
neurosurgery, eyes and
ENT (n 40)

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errors. Later, the random errors are examined to see if they have been affected by the
intervention. Put simply, the ARIMA technique de-trends or stabilizes the time series
to establish whether or not there has been a step change following the intervention,
as shown in Figure 2. Once stabilized, a standard t-test can be used to analyse the
statistical significance of the step change in the data (Cook and Campbell, 1979).
3. Results
3.1 Effect of TOC on performance indices
As shown above, in Figure 2, the effects of TOC on eyes and ENT departments were in
the predicted direction. For instance, the B value for outpatients seen within 30 min
indicates that following TOC, on average 184 more people per month were seen within
30 min in Eyes and 108 more were seen in ENT. Out of 18 measures, 16 went in the
direction of the hypotheses. Measures that were predicted to increase went up,
measures that were predicted to decrease went down simultaneously. Although in
most cases the effect of TOC was non-significant and effect sizes were modest, it can be
demonstrated that the probability of these changes in the predicted direction by chance
alone was very low p , 0:0006: In neurosurgery, however, there were only four
changes in the predicted direction and each of these changes was non-significant. We
now move to examine the impact of TOC on individual indices by department.
GP referrals have increased in neurosurgery, eyes and ENT subsequent to the TOC
intervention, but not significantly. The reader should note that GP referrals is not a
performance measure, but an indication of the pressure Outpatients departments
undertaking this study are under.
The number of patients seen in outpatient increased for eyes, neurosurgery and ENT.
These results are in the direction of the hypothesis. However, the changes due to the
intervention were not significant, although for ENT the change approaches significance.
The number of patients seen within 30 min increased significantly for eyes and
ENT. In eyes, the intervention resulted in an increase of 184 patients each month over
the 28 months subsequent to the intervention. In ENT, over the 12 months subsequent
to the intervention, there was an increase of 108 patients each month. Both results were
significant and in the direction of the hypothesis. In neurosurgery, the number of
patients seen within 30 min decreased. This was not in the direction of the hypothesis.
Cancellation by hospital of outpatient appointments decreased for eyes and ENT.
These changes were consistent with the hypothesis. However, they were not significant,
although approaching significance in the case of ENT. For neurosurgery, cancellations
of outpatient by hospital increased. This was not in the direction of the hypothesis.
Cancellations for outpatients by patients who did not arrive (DNA) decreased by
33 patients each month in ENT, over the 12 months subsequent to the intervention.
This result was in the direction of the hypothesis but was not significant. The results
showed that DNA increased for eyes and neurosurgery. These results were not
consistent with the hypothesis.
The number of patients waiting over 15 months for theatre decreased for all
departments. These results were not significant, but consistent in direction with the
hypothesis.
The total number of patients on waiting lists decreased in all the departments.
These findings were in the direction of the hypothesis but were not significant at the
0.05 level, although in the case of ENT the fall approaches significance.

FCE showed an increase in both neurosurgery and eyes as a result of the

intervention. These changes were consistent with the hypotheses. However, neither
result was significant. For ENT, the number of elective FCE decreased, which was not
in the direction of the hypothesis.
FCE non-elective increased in both eyes and ENT. These results were consistent
with the hypothesis. In eyes, the change was significant, with an increase of six patients
each month over the 28 months subsequent to the intervention. In ENT, the increase
approached significance. In neurosurgery, the number FCE non-elective decreased
which was not consistent with the hypothesis.
Both eyes and ENT increased the number of FCE day cases. In eyes, the
intervention was significant with an increase of 70 FCE day case patients each month.
This result was consistent with the hypothesis. Neurosurgery decreased the number of
FCE day cases. This was not in the direction of the hypothesis.
4. Discussion
The main findings of this study indicate some support for the hypothesised impact of
TOC in eyes and ENT, but not in neurosurgery. These results would appear to
demonstrate an effect in the predicted direction rather than a dramatic process of
change. The most clear-cut changes were within eyes, particularly regarding
throughput in theatre. The above results are in line with Willcocks et al. (1997),
Packwood et al. (1998) and McNulty and Ferlie (1999), who argued that the impact of
BPR as a change process in the NHS was incremental rather than dramatic.
The study demonstrated that TOC as a methodology can make an impact in the
health sector on complex issues such as waiting lists. This is consistent with evidence
about the impact of TOC in the private sector (Vollmann, 1986; Meleton, 1986; Gillespie
et al., 1999; Miller, 2000).
Guzzo and Shea (1992) argue that the sociopsychological context is important
when examining the effectiveness of change processes in organisations. In the current
study, the merger between the RI and John Radcliffe into the Oxford Radcliffe
Hospitals NHS Trust was an important contextual factor impacting on the success of
the TOC methodology.
In June1999, the RI merged with the John Radcliffe. This resulted in a gradual
shift in the hospitals organisational culture. Towards the end of the study (i.e. end
of 2000), staff at the RI reported several changes. There was a move of several
senior people, including the CEO, from the RI to the John Radcliffe. Staff reported
feeling more distant from decision-making. The uncertainty over the direction of
the new Trust was seen as a potential threat to TOC on the basis that some
control over local priorities and decision-making was being lost. The merger also
highlighted anxieties about security of jobs. Some of the support services of the
(RI) hospital were moved to the John Radcliffe. Staff expressed fears of losing
what they saw as the family culture of the RI to what they perceived as the much
more numbers-driven culture of the John Radcliffe. It can be argued that the
impact of merger was powerful, and distracted staff from the implementation of
TOC. As staff were anxious about their jobs in the new management structure, it
was unlikely that energy and commitment for TOC would be maintained. In these
circumstances, the fact that TOC produced any beneficial changes at all, not least
over a sustained period, maybe attests to its potential effectiveness.

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Another important factor in understanding the main findings concerns the degree of
variability and complexity of the different patient processes. First, the degree to which
processes can be standardised will depend on the degree of case mix variation a high
proportion of cases requiring relatively similar interventions will reduce variability.
Secondly, the degree of reliance on resources outside the direct control of the speciality
area will influence variability. These factors include the extent of cross referral to other
specialities; reliance on any services off site including diagnostic and other clinical
support services; the number of outliers on or from the ward; and the number of
tertiary referrals. Where these factors are significant, the clinical area will have
significant reliance on resources outside its immediate influence, leading to some loss
of control over operational performance.
Thirdly, the exposure of the speciality to operational disturbances will influence
variability, for instance through staff turnover or sickness; disruption to elective work
as a result of surges in emergencies; budget cuts; and the extent of other operational
problems in running the department.
Both eyes and ENT departments are relatively self-contained. There is no major
reliance on other support services. Emergency work rarely impinges on routine work.
The case mix is fairly predictable, with the majority of cases admitted for one of a
limited range of routine procedures. For example, in eyes the main procedure is for
cataracts. The relatively routine case mix, combined with the self reliant nature of both
eyes and ENT departments, makes it easier for staff to arrange a buffer area with
patients who have completed a number of pre-operation tasks (e.g. blood pressure) and
are ready to go into theatre. The positive finding in ENT and eyes may relate to these
characteristics in their settings, which enable more control and self-reliance over
operational issues. They may also be linked to the ease in which a buffer before the
bottleneck can be used and implemented. Furthermore, relative success in both ENT
and eyes maybe linked to the fact that during the study no major disruptions/events
were reported in these departments.
In contrast, neurosurgery has a number of unique factors that reduce the
receptiveness of the department to the TOC implementation. Neurosurgery is a bigger
system with a larger number of dependent events including a much more complex
preparation of patients for theatre. This means that for neurosurgery the concept of a
buffer is difficult to implement. Furthermore, unlike eyes and ENT, neurosurgery is
less self-contained and is much more open to operational disturbances. It has a fair
degree of reliance on ultrasound and other diagnostic services. In addition, the case mix
is unpredictable and the nature of neurological disorders can be obscure.
For example, the time needed to complete brain surgery can vary significantly
between patients and, in many cases, the completion time can only be reliably
estimated during the actual operation. In comparison to ENT and eyes, the
management of emergency work does impinge to a significant degree on elective
workload. The above unique factors of neurosurgery may in part explain the lower
level of TOC impact observed in this study.
The differences in the service settings appear to have influenced the ease with
which TOC can be applied. The closer that the work of a department resembles the
relative predictability of a production process, the more straightforward applying TOC
will become. The evidence that the complexity of patient processes influences the
impact achieved through a change programme supports the theoretical understanding

of applying operations management techniques in a service setting (Tidd, 1998) and

also reflects the experience of BPR in the LRI (McNulty and Ferlie, 1999).
Another possible interpretation of findings would involve factors that influence the
success or failure of programmatic change. Pettigrew (1998) argued that change
methodologies should be linked and customised to local business needs. In this study,
there were clear attempts to adapt TOC to the local objectives of the different
departments. Local customisation of the TOC process has been important to its
acceptance. In ENT the early impetus was not only targeted at increased throughput
but also at the need to reduce staff stress. This customisation was almost certainly
essential to the continuation of the initiative in ENT as it addressed the central
challenge facing staff in the workplace at that time. The TOC process focussed much
more upon engaging key managers and clinicians and front line staff such as nurses
and administrators, in the process and allowing considerable flexibility in the
implementation.
This was in contrast to the level of input seen in, for instance, the BPR project at LRI
(McNulty and Ferlie, 1999). The outcome of TOC appears to have been some trade
off related to managerial outcomes in the interests of securing local ownership to
the change process. The outcomes also relate to the review of the literature and the
research findings of West et al. (2000, 2004) where teamwork and other HR processes,
including employee participation, were seen to be related to organisational
effectiveness. The teamwork and participative base of the process is likely to have
been a significant factor, and in contrast to the view of Nave (2002) this study
demonstrates that TOC interventions can entail significant involvement in and
understanding of the process on the part of the workforce. Such involvement
and understanding may be particularly important in systems where policies and
behaviours are the major constraints, as they may be within the NHS.
Pettigrew (1998) argued for key milestones for monitoring long term changes. These
ensure that staff do not lose interest in the change process. Successful implementation
would include project management arrangements to steer the changes, while providing
reward and recognition to reflect the new way of working. Effective project
management is also highlighted in TOC which provides tools and methods to promote
it (Bradbury-Jacob and McClelleand, 2001). In this study, the departments that
undertook the change process had variable levels of success in pursuing robust and
systematic project management of the TOC process.
Both ENT and eyes had a TOC committee that met every fortnight to discuss new
ways forward and review progress. However, overtime due to the high workload, and
the lack of reflection time mentioned earlier, meant that staff found it difficult to attend
meetings. Neurosurgery did not have a TOC project co-ordinator and, in line with
Pettigrews findings, did not achieve results. Overall, it can be argued that the
organisational culture in the NHS does not encourage and support systematic project
management. In his evaluation of clinical governance initiatives in NHS mental health
trusts, Worrall (2003) in preparation cites a catalogue of obstacles to success including
lack of time and funding for project management, inadequate staff training to
implement the new procedures and constant disruption from mergers between trusts
and changes in government policy and initiatives. In this study, owing to the daily
work pressures, basic project management procedures were ignored. This might
explain the limited effect of TOC in some areas.

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The impetus given to the project by the director of operations (DOP), and the
personal credibility of the DOP, was seen as important by several staff. This helped
shape attitudes towards TOC as a force for the good. Similarly, in both ENT and
eyes, the clinicians had become involved and interested which helped generate a sense
of team ownership of the TOC process that is a necessary condition for the successful
implementation of TOC.
The current design was limited owing to the withdrawal of the Southampton control
group. Therefore, the research design could not control for other external events that
might have impacted on departments undertaking the TOC (e.g. extra cash).
As a result, confidence in the accuracy of, and ability to generalise from, the
findings of this study are somewhat limited. Another main limitation of a time series
design is the effect of history (i.e. simultaneous changes or confounding factors).
This is of particular importance in this study, where the experimental groups differ
from each other in relation to the nature of their task and therefore there is higher
probability for unique local historical events to make an impact and confound the
findings (Cook and Campbell, 1979). The switching replication design, and having a
non-equivalent control group, does help to control for some of the effects of history.
However, not all of these threats can be ruled out. Cook and Campbell argue that it is
important to make records of all the effect-causing events that could influence the
results of a quasi experiment. They argue that it should be possible to ascertain
whether any of them were operative during the study.
Future research should aim to compare TOC with other whole system
methodologies. This means running various whole systems approaches in different
sites and recording both similarities and differences. Future work should also aim to
record not only what changes occur but also what exactly led to those changes, again,
to establish still further the individual and group processes that have led to
behavioural change. Finally, this study took place in the NHS in the UK. It is important
for future research to consider hospitals in other cultures and other healthcare systems
with different histories.

5. Conclusions
This study has demonstrated that the application of TOC can have a beneficial impact
on bottom-line indicators in a health care context, on such things as waiting lists
and patient throughput. Moreover, TOC has the potential to effect system-wide
changes rather than local efficiencies as the movement of several indicators up or
down simultaneously, shows. TOC has the benefit of not being a one size fits all
technique for bringing about organisational change because all stakeholders are
engaged in identifying both problems and solutions. Thus, it can be customized to local
needs and conditions and promote ownership of change initiatives.
However, the complexities of bringing about change in a system as complex as an
NHS Trust have also been highlighted. The changes tended to be small scale and
incremental rather than dramatic and TOC did not have an impact on neurosurgery.
In the latter case, the complexity of the neurosurgery system may have been a factor.
For TOC to have been a success, the intervention would have had to address issues in
this wider system and not just within the department. Thus, TOC worked best in eyes
and ENT where routine surgery is the norm and had no effect in neurosurgery where

presenting conditions are more ambiguous and life-threatening emergencies are

common.
Nevertheless, TOC methods were reported as being successful in the change
management entailed by the merger of two New Zealand banks (Mabin et al., 2001).
This study promoted the use of TOCs thinking process methods to overcome and
harness resistance to organisational change. In neurosurgery, there was a lack of
clinical leadership and project management that were important for effecting change in
the other two departments. Thus, one implication of this research is that these two
aspects of change interventions must be given particular emphasis in the NHS and
maybe in other types of organisations too. It is also possible that the flexibility of TOC
interventions could have been better employed with more emphasis on thinking
processes in the neurosurgery workshop.
However, perhaps the most important lesson for those who wish to reform the NHS
comes from the impact of a change which occurred quite separately from the TOC
process: the merger with a larger NHS Trust. This was seen most clearly in another
parallel study which investigated the feelings and morale of staff throughout the
period of the TOC intervention in ENT (Lubitsh, 2002; Lubitsh and Doyle, in
preparation). A frequently occurring complaint from staff was that the merger process
was against the spirit of TOC and was undoing all the improvements which had come
out of it. These comments are particularly interesting for the support for TOC and the
change process which they demonstrate. The disruption and dissipation created by
the merger could well explain the modest effect sizes in the findings. In an organization
such as the NHS where change fatigue may well be endemic, it would be as well for
todays reformers to let their left hands know what their right hands are doing.
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