NHS productivity: a Q&A from diverse perspectives
The political debate around NHS budgets is becoming increasingly complex. While the key message – the NHS needs more money – has remained relatively consistent, the narrative is shifting even more to ensuring the money is spent at the right time and in the right way.
Lord Darzi’s report on the state of the NHS revealed crumbling hospitals, lack of scanners and falling behind the private sector on digital innovation. The Government announced the same day there would be a 10-year plan to reform the NHS, making it clear there would be no extra funding without reform.
The productivity debate adds to the complexity around debating how much cash the NHS should get and how. Since the pandemic, NHS funding and staff numbers have increased at a faster rate than the number of patients being treated in hospitals. This implies that the NHS is less productive than it was pre-pandemic.
We’ve asked four experts to break down the complexity to explain productivity in the NHS, potential solutions for the puzzle and the role of staff engagement within it.
Dr Na’eem Ahmed, Chief Medical Officer and Co-Founder of ImproveWell
What is productivity, how is it measured and how does staff engagement play a role?
NHS productivity determines how much care is delivered with the funding available. It is measured by changes in the volume of output divided by the change in volume of inputs, essentially quantifying how much we are getting for this investment.
Outputs are measured by the volume of activity in hospitals, primary care, and NHS-funded but privately-delivered care. All of these figures are then adjusted for quality, including survival rates, waiting times and patient surveys.
Inputs consist of three components, which are all tricky to measure: labour, goods and services and capital consumption. Weighting and counting goods and services across the whole system is challenging, as is quantifying capital consumption. But measuring labour is not straightforward either – it is currently oversimplified and risks painting a false picture of productivity because it isn’t weighted for quality. Experienced clinicians are shown to make decisions faster and make fewer mistakes.
For me, it’s a no-brainer that the quality and experience of healthcare professionals should be accounted for when measuring productivity. If you have more staff but they are mostly inexperienced, because more experienced staff are leaving due to burnout and dissatisfaction, you are likely to see worse outputs – both in terms of quantity and quality.
While patient experience surveys feed into the output measure of productivity, there is a huge gap when it comes to including staff engagement in the measurement of productivity. Staff sentiment is a smoke detector for burnout, which has a big impact on productivity. There is a focus on measuring tasks completed but emotions are a good indicator of productivity. Staff surveys and real-time feedback, if added to how productivity is measured, would significantly improve the quality of the productivity figures and the conversations we have around how to improve the NHS productivity challenge.
Nicola McQueen, CEO of NHS Professionals
How do NHS staff feel about the productivity puzzle and how does this affect their wellbeing?
Productivity might seem like something that is only discussed at a senior level or amongst those with control of budgets. But it impacts staff at all levels. Imagine the impact on your motivation if you’re feeling overworked and under-resourced, and then told staff are doing less with more resources.
It is even more challenging for flexible workers when they are told that the flexible workforce ‘is part of the problem’ because they are more costly than their substantive counterparts. Earlier this year, Minister of Health, Karin Smyth, speaking at the Institute for Government, suggested that spending on agency staff is a big proportion of the £10bn of waste identified in the NHS. She said that the Labour Government would ‘wage a war’ on such waste seeking measures to reduce agency spending.
Transitioning these workers to staff banks therefore provides a route to improved efficiency. The Audit Commission has demonstrated that bank staff offer the most efficient deployment option – not just over agency, but also over substantive, as they don’t carry the on-cost associated with things like sickness absence, which has been growing in the substantive workforce. Benefits also arise where bank staff can be deployed more flexibly across systems to ensure that skills are available where they are most needed.
Recently I attended a Chief People Officer conference that was all about productivity and equipping leaders with the tools to have conversations and create a shared understanding of the productivity puzzle and why more money and more people have not led to more productivity. As Thea Stein suggested in a recent Nuffield Trust article, without the conversation, falling productivity hangs over us all as a statement of accusation and dismissal of personal effort and worth. Nothing could be more demotivating.
She goes on to suggest that we need to ‘get inside individual services with curiosity and compassion and see what is really going on from a cultural perspective too’. The NHS staff survey tells us that many staff feel they are experiencing unrealistic time pressures and working extra hours and a considerably higher proportion than we would like, say they feel burned out. No one that is overwhelmed like this can be productive. But are we listening enough to what they have to say about how we could reverse the situation and help them to feel better supported and work more productively?
Lord Darzi, in his recent review of the NHS, suggests that falling NHS productivity doesn’t reduce the workload for staff – “it crushes their enjoyment of work”. He talked about clinicians spending much of their time trying to resolve process problems to manage the throughflow of patients rather than using their skills to provide quality healthcare.
My experience of working closely with the flexible workforce suggests that, every day, they want to follow their vocation. ‘They want to provide the best care for patients’ – and that means working at ‘the top of their license’ (i.e. using all of their skills and experience to offer each patient they engage with the best service they can). In fact, it is sometimes what drives individuals to work on a staff bank as it is through bank shifts that they can work unencumbered by administration and trying to overcome process barriers. That should tell us a lot about what motivates people and what they perceive as ‘quality work’.
The other day I was with a group of Trust and ICB leaders and we were discussing how we can better engage and motivate our workers and remove the things that crush their enjoyment. It led us to discuss the importance of ‘delegation of tasks’ and ensuring that healthcare professionals focus on the tasks for which they were trained – with other tasks being delegated to the unregistered workforce or even the unpaid workforce. Armed with the right training (and training to task), others can often take tasks away from our qualified professionals to free them up to do things that motivate and engage them – and allow them to work positively and productively.
Dr Anas Nader, Co-Founder and CEO of Patchwork.
What role do you think technology has to play in addressing the productivity challenge?
Leveraging workforce data and insights will be a game-changer for boosting productivity within the NHS. Reliance on outdated processes and fragmented staffing systems has often led to ineffective staffing and unnecessary costs. And without real-time access to workforce data, NHS organisations are forced to react to staffing issues at the last minute instead of managing them proactively. With four key technological changes, NHS teams can transform datasets into actionable insights that empower teams to be as productive as possible.
- Inconsistent decision-making: Making any decision without all the necessary tools is difficult. However, what is frustrating for many managers within the NHS is that the data and insights are there, but many systems don’t easily surface this information for teams to access when necessary. This impacts productivity in several ways. We know more experienced staff who know a healthcare setting deliver more effective care. At the moment, decisions are sometimes made on how best to deploy staff inefficiently because the data is not presented clearly for staffing teams to utilise, leading to situations where, for example, an agency worker is deployed over a known bank worker.
- Easily accessible workforce insights: We need to use reporting technology to enable staffing managers to leverage real-time data insights that can inform decisions about workforce deployment, so resources are used where they are most needed. One example of this is shift lead times. If managers can identify the average lead times for different shift bookings, they can more easily and accurately decide the appropriate time to broadcast, or escalate, specific shifts to maximise fill rates and minimise staffing spend.
- Poor engagement from clinicians: With many traditional processes, recruitment and retention efforts can be inefficient and costly, often involving long wait times and manual approvals, which can deter clinicians from completing certain processes, such as joining a staff bank. Without visibility into these issues, organisations risk losing valuable workers before they have even started. And when managers aren’t able to see the number of available clinicians and where they can be most appropriately deployed, it becomes even harder to plan, significantly reducing productivity as a result.
- Better utilisation of the workforce: Technology will be key to ensuring staff are deployed where they are most needed, quickly – a crucial part of improving productivity. By tracking the number of applicants awaiting approval to staff banks and their specialities, for example, NHS trusts can prioritise onboarding for high-demand roles. And monitoring this data over time will help – managers can understand where delays are occurring in onboarding, and extra effort can be put into re-engaging specialties.
With these tools, organisations can confidently navigate the complexities of workforce management, making informed choices that increase productivity, drive efficiency, and support a happier, more engaged workforce.
Dr Amar Shah, National Clinical Director for Improvement at NHS England and Chief Quality Officer at East London NHS Foundation Trust (ELFT).
How do we frame the productivity challenge in a way that connects with our staff and service users?
Part of the NHS productivity problem lies in the language we use. Most people in clinical services will feel alienated by the words that often come with a productivity discussion – the language implies that we’re not working hard enough, or need to work harder. This can be demoralising, particularly if we make crude comparisons between services, where one might appear to be ‘more productive’ than another.
Definitions of quality (whether the original three-part definition by Darzi of patient safety, clinical effectiveness and patient experience, or the Institute of Medicine six domains) rightly include efficiency and productivity as crucial components to the provision of high-quality care. But how do we shift the conversation away from a preoccupation with activity, numbers and language that doesn’t resonate with what matters to staff and patients, to one that is framed around doing the most, and having the most impact, with what we have, grounded in really understanding what matters most to people?
One great example that I heard about recently from Louisa Wickham, National Clinical Director for Eye care in England, is the introduction of diagnostic lanes in ophthalmology at Moorfields Eye Hospital, which streamlined interactions with clinicians. Diagnostic hubs were set up and run by technicians, patient data was reviewed by the clinician and patients were only invited for a face-to-face appointment if there was an issue that needed follow up. All of this was grounded in really understanding what mattered most, and what added value, to the patients and staff in the service.
Communication was crucial to the success of this initiative – patients could have easily felt they were losing out on face-to-face time, but they were reassured that they were receiving quality care and, when they did need face-to-face follow up, waiting times for appointments were cut by around an hour, plus travel time saved. This example shows the possibilities of improving people’s experience and access, whilst improving productivity and efficiency, through focusing on those aspects of care that really add value.
We tend to look for simple answers to productivity, even though we know it’s more complex than this. In fast-paced, stretched environments like the NHS, we sometimes want there to be a simple solution. But the answer is likely to be complex and specific to the local team and context. Creating a culture where we can talk openly and listen to staff and patient feedback will be key to unlocking these local opportunities, alongside leadership that demonstrates humility and curiosity in exploring new possibilities and solutions.
I know from our own quality improvement work at ELFT that so much of it has been able to demonstrate improved productivity and efficiency. However, that has never really been the goal. Teams at ELFT focus their improvement work on what matters most – to our service users and staff – aligning their efforts to the most pressing and important improvement opportunity. Through working together, truly and deeply understanding the system first, enabling creative thinking and testing, we can improve access, safety, cost – and through doing this, find ways to remove waste and be more efficient and productive. In my experience, all our clinicians and staff in healthcare understand the finite nature of resources that are available, and want to make sure that these are used to best effect.
Conclusion
While there is no simple solution to the NHS productivity puzzle, it’s clear reframing the conversation and a shake-up of the hierarchy seen across the NHS are key. They have the potential to not only change the way productivity is measured, by reflecting staff sentiment, burnout and experience in its measure, but could also go a long way to improving productivity itself by devolving decision-making and speeding up the implementation of technological tools that could improve the experience of staff and patients.
