The NHS has a productivity challenge. Quite simply, more money and more staff are not translating into enough care. A brand new government, in power with a policy that “the NHS is broken”, has commissioned surgeon Lord Ara Darzi to carry out a review tasked with telling “hard truths” about the NHS’s performance. And there is perhaps no harder truth than the problems posed by the NHS’s productivity woes.
To have a better chance of a realistic and comprehensive plan to fix the NHS – which tackles the health service’s productivity conundrum in a more effective way than we’ve seen so far – there needs to be a broad agreement on what the root causes of the productivity issue are. That should be straightforward, but so far it has been the opposite.
Earlier this year, I laid out my central thesis that we are not having the conversations we need about productivity, at a local or national level. In this piece, I further examine the NHS’s productivity problems and explore the many theories about productivity, drawing on established research and thinking.
I argue that reaching a consensus on the roots of the problem, working collaboratively in a psychologically safe environment, is vital if the health service is to use the resources that it has in the best possible way.
The conundrum
Simply put, productivity is what you are getting out for what you are putting in. And at the heart of the debate over NHS productivity is a conundrum: more money in, more staff, lower outputs (or outputs that are only marginally higher, and so considered similarly unsatisfactory).
Since the pandemic, we are getting less from the acute hospital sector (in terms of the numbers of people seen or the numbers of procedures undertaken) despite increases in staff and multiple injections of new money (albeit often short-term funding). There has only recently been a recovery in A&E attendances, emergency admissions and outpatient attendances, and volumes of planned care with a procedure are still below pre-pandemic levels.
But despite there being more staff and more money, front-line staff say they have never worked harder or felt more overwhelmed and tired with the work they are asked to do, which is something the public see and recognise.
The language used in this debate doesn’t help. No patient has ever talked about outputs, and raising the number of those outputs is not the kind of language that resonates with clinicians and managers either, who are more likely to be motivated by delivering better care for the patient in front of them.
A defensiveness and lack of trust – between clinicians and managers, managers and officials, officials and ministers, ministers and backbenchers – means that conversations about NHS productivity often start with a discussion on what we are measuring and why – whether your “apples” are my “pears” – or how the metrics or quality adjustments are not comprehensive.
It is not enough, however, to argue about the framing of this forever.
Moving beyond established narratives
The productivity debate is often contextualised within neoclassical economic theory – which assumes that people always make rational and often self-interested decisions. But behavioural economics – which recognises that people's behaviour is rarely rational, and is shaped by a mix of environmental factors – might be a better lens through which to view productivity in the NHS.
In my presentation to the Nuffield Trust Summit back in March, I called for a “productivity truce”, where all parties acknowledge how they have become sucked into subculture narratives of blame and easy tropes, such as blaming managers for supposedly not knowing what they are doing or clinicians for supposedly not working hard enough, or that it’s all about more capital or that the magic of AI will solve it all.
Setting these tired narratives aside and moving onto a more open conversation – one that seeks explanations and co-produces solutions – is now needed. A thorough look at theoretical explanations for the productivity conundrum will be a helpful start.
Lack of investment in capital and digital
Some theories on productivity are oft repeated and, to an extent, clear. I would pick out those concerning a lack of investment in capital and digital. Diane Coyle in her lecture last year for the Health Foundation discusses this in detail and outlines why capital matters:
“An analogy is to think of a construction site where a worker is going to become more productive if they have a mechanical digger rather than a spade. In economics, this is known as ‘capital deepening’: investment in more capital equipment per worker will improve labour productivity.”
This Health Foundation graph makes the case for why we really are in trouble when it comes to capital investment in England in the NHS.
Professor Coyle argues that we should indeed treat investment in capital in the NHS as part of national infrastructure investment, which is a compelling argument. Capital should definitely form part of our understanding about the productivity issue and it’s important not to lose sight of its huge significance. But it doesn’t explain everything.
Discussions around how technology and digital have contributed to the NHS’s productivity woes are not new. The Health and Care Select Committee's evaluation of the government’s commitments on the digitisation of the NHS does not paint a good picture.
But what of AI, can it save us? Well the answer is: a bit, in the long term, in a nuanced way and as long as you take clinicians with you every step of the way, as described by Jess Morley at our 2024 policy Summit.
Previous research has suggested that the biggest benefits of technologies in the NHS are likely to be those that help with administrative and operational tasks, as well as clinical tasks, and that the more immediate gains for the health service may come from “optimising and spreading existing technologies” rather than adopting new ones.
It’s also important to consider the time it takes to roll out new technology, then embed it and get it adopted, as we emphasised in our recent work on remote and digital general practice. A recent report by the Tony Blair Institute also reiterated how long things can take:
"The advent of personal computing, for example, began in the 1970s but took until the mid-1990s to show up in productivity statistics. Two factors determine the lag between tech creation and its impact on productivity: the speed and intensity with which the technology is adopted by households and businesses, and the degree to which existing work processes must be rewired to make best use of the new tools."
So technology does and will impact on productivity, but probably not tomorrow or next week. So we urgently need to look at the workforce.
The make-up of the workforce
Earlier this year, we looked at the changing experience levels of NHS staff, in which we described how a higher proportion of health service workers being new to their career and role, as well as to the NHS more generally, provides important context for the productivity debate.
There is a lot to explore here, but there isn’t much further commentary on it. Why not? Having so many young people within the NHS in our biggest workforces – nursing and allied health professionals – is a positive thing and a cause for celebration, rather than something to disparage.
While the wider literature suggests – albeit not consistently – that there could be a link between clinicians’ age and productivity, there is a lack of specific evidence on how the demographics of clinicians, including age, gender and parental responsibilities, are associated with productivity.
But a more open and curious culture would help us to understand more, to then possibly consider appropriate interventions that are more nuanced than current policy. Would we need different approaches to education and training? How does this profile intersect with the ambitions of the long-term workforce plan?
The chart above also shows the significant rise in the numbers of overseas nurses into the workforce. There has been significant commentary about this, including our own, but its link to productivity has not been explored or considered enough. It seems reasonable to suggest that even experienced staff from overseas will be less productive when they join a new health system and that they will need more support and supervision.
Complexity of patients
Is the productivity conundrum to do with patients themselves, and what economists call the demand side of the equation? Are people sicker? Are they presenting with more issues at one appointment/one inpatient stay? Do they therefore take more time and need more care?
There have been several descriptive studies in this area, documenting a rise in patient complexity. But we do not know what effect this has on productivity. It is not unreasonable to assume that if someone’s presentation is more complex then they are going to need more work.
Again, there is little work that unpicks the links between complexity and productivity. Our ongoing work at the Nuffield Trust is exploring how, while nursing care hours per patient bed days initially surged over the peak of the pandemic (as in patient numbers dramatically plummeted), they then appeared to stabilise over 2023 at a rate significantly higher than the pre-pandemic period.
Health care support workers have provided more additional minutes of care than nurses and midwives (compared to 2017/18)
Chart
It is interesting, but when we note that in our sample of acute trusts this growth is of health care assistant (HCA) time and not registered nursing time, what does it tell us? We can all hypothesise. Is this the use of different combinations of health care professionals (known as skill mix) slowing work down, is it providing a higher level of care because patients are more complex, or is it ineffective? Is it happening because there aren’t enough nurses?
More research and conversations with front-line staff, as well as with those making such staffing decisions, are needed.
Strikes
The strikes by NHS staff in recent months have been controversial and well documented, but why staff have been striking is just as concerning when it comes to understanding productivity. Beyond money, we hear of low morale, the experience of junior doctors being allocated across the country with no regard to their lives and choices, the lack of support and proper training, those endless stories of lack of access to food and hot drinks, the cost of car parking, the poor rostering. You only need to spend a short time on medics’ social media to understand that it’s not just about pay.
Yet while the strikes are a symptom of poor workforce morale, they will have implications for how productive the striking workforce will be, even if the exact impact of that to date has been contested.
The impact of wellbeing and staff morale
Beyond the strikes, wellbeing in general across the NHS is an important part of this story. Lower morale across the health service inevitably has a knock-on consequence on how much discretionary effort workers will offer to a health service that has become reliant on staff picking up extra duties and tasks. Again, however, it is important not to fall into lazy tropes. Staff survey results seem to have stabilised at least this year, and in some trusts overall satisfaction has gone up.
Looking at and understanding those trusts who have achieved these results, and how this interacts with productivity, would be a good angle to explore. Are trusts with good psychological safety and with good results on staff experience doing better on productivity metrics? There seems to be a lack of research exploring this question. There is certainly a lot of talk about the loss of discretionary effort, but it is very difficult to quantify.
There is, however, significant research literature looking at the links between staff satisfaction in general and its impact on organisational performance and patient outcomes. A report from Martin Powell and others on staff satisfaction and organisational performance, for example, used data from several years of the UK-wide staff survey with trust-level measures of staff absenteeism, turnover, patient satisfaction, mortality and infection rates gathered from the same NHS years they report. It concludes that:
“Better staff experiences (particularly those associated with better wellbeing and better job design, and more positive attitudes about the organisation generally) were linked to lower levels of absenteeism and greater patient satisfaction.”
What we don’t know though is whether these places are more productive simply in terms of the amount of work they can do. Do they have lower waiting lists, are they more efficient in their theatres?
Any organisation that is really serious about tackling productivity issues should be thinking carefully about how staff satisfaction and team working can impact on the work they are doing.
Google undertook just this when they established Project Aristotle in 2015. Their aim was to understand what made the most effective and productive teams across their global business. The hypothesis they started off with was that it was a blend of skills and experience that made the most effective team: put the best people together and you will get the best teams was their accepted wisdom. Their subsequent analysis – over years, continents and over 180 teams – concluded that this was wrong.
“Most confounding of all, two teams might have nearly identical make-ups, with overlapping memberships, but radically different levels of effectiveness. At Google, we’re good at finding patterns, and there weren’t strong patterns here.’’ (New York Times, 2016)
What they did find, however, was that highly productive and effective teams depended on five key variables:
- Dependability: Trust is crucial. Team-mates need to rely on each other to deliver on commitments and meet expectations.
- Structure and clarity: Clear roles, goals and expectations contribute to team success. When everyone understands their responsibilities, collaboration becomes more effective.
- Meaning: Teams perform better when they find their work meaningful. Connecting individual tasks to a larger purpose fosters motivation and engagement.
- Impact: Successful teams see the impact of their work. Knowing that their efforts matter drives team members to excel.
- Psychological safety: Team members must feel comfortable taking risks and expressing their thoughts without fear of ridicule. When psychological safety exists, teams thrive because everyone supports one another and encourages open communication.
There seems often to be a reluctance to accept in the health service that productivity is inextricably linked to these so-called “softer” factors.
The taskification of health care work and the development of a new workforce
And now we come to McDonalds, or more accurately the increasing McDonaldisation of work in the health service and its impact on productivity.
The McDonaldisation of work refers to a concept developed by sociologist George Ritzer in his 1995 book “The McDonaldization of Society”. It described the application of fast-food management principles to various sectors, emphasising efficiency, predictability and control. While it offers advantages in terms of consistency and speed, it has been argued that it can lead to negative effects, such as decreased worker autonomy and reduced job satisfaction.
A wealth of literature looks at the effect of breaking up care into its constituent parts, or developing new roles to take on one part of an overwhelmed professionals’ portfolio, but there’s been little published that specifically looks at the impact on productivity.
A report this year by Professor Alison Leary and Dr Geoff Punshon for the Queen’s Nursing Institute explored the multiple challenges posed by the introduction in England of the Additional Roles Reimbursement Scheme (ARRS) on the work of GP nurses and GPs. Some of its conclusions were:
“General practice nurses felt that more people delivering care who could not complete episodes of care led to more ‘taskification’: task orientated, disjointed care, repetition of work (for workforce and patients) and subsequent risk as care became fractured.
“ARRS roles contributed positively to distribution of work and clinical outcomes/quality of care when used in context of professional expertise, for example mental health nurses, pharmacists undertaking medicines reviews, or dietitians offering an extra service previously not available. When roles were used out of normal context and jurisdiction, they impacted on the workload of nurses, as ARRS professionals sought more advice and support and were leaving work incomplete.”
This is only one example, but it underlines the importance of considering the complexity of introducing new roles into the NHS and the unintended, or at least unscoped, impact on productivity. Anecdotal evidence from across the service backs up the assertion that “taskification” and the introduction of new roles can have many positive effects, but also unforeseen consequences in terms of the time taken from other staff in supervision and training.
This is not an argument against the introduction of new roles or trainees, which is a key part of the long-term workforce plan, but rather an argument for understanding the impact on productivity, to both understand and plan for this.
Ultimately, it’s about psychological safety
The productivity challenge isn’t simple. The roots are complex, and the solutions need to be multi-layered and locally determined. What explains the productivity issues in district nursing place X will be different from what explains the challenges in orthopaedics in place Y. The theories, however, that can be used to frame the debate remain the same.
In this long read, I have looked at a number of theories about why the NHS is struggling with productivity. But few of these can be comprehensively reviewed without the context of a psychologically safe environment.
The NHS needs the space and time to explore these theories openly, without fear of blame and accusation and with the acceptance from all parties that understanding and solutions will take time. Labour recently called for radical candour in the debate, and being able to speak openly and honestly and with compassion is crucial in the productivity discussion. It should form part of the framing of the new Darzi review and construction of the 10-year plan.
Building psychological safety takes time and there are few shortcuts. It’s predicated on trust, and it works when both parties have positive experiences with each other. When it comes to productivity, the new government has to be prepared to really listen, take time to build respect and trust, explore the unintended consequences of what seems like a good target, be prepared to be wrong, and to have evidence-based and intelligent conversations. There is a need to ask “why” several times, not just once – and to really listen to the answer.
Calling a truce on this subject and refusing to be sucked in to the blame game and easy tropes should be at the heart of truly understanding the productivity challenge. It could even be an interesting and rewarding experience in which staff would engage and care would improve.
Using the resources we have in the most efficient and careful way, to achieve the best outcomes for patients, is what everyone wants. That’s what productivity means. It shouldn’t be a battleground.