Over my career, when I’ve said to a member of staff “oh I was expecting that work on Monday, what's happened?”, much depends on how they understand my intent or, to put it another way, how they ‘read’ me. A lot also depends on our relationship, our history, what their experience is of similar conversations, my tone, even my body language. Depending on all these factors, our conversation can go in one of two major directions.
The first is that the member of staff hears the question, reads my mood and body language and believes my intent is good, and that I am open to listening to what they really have to say. So we settle down and they explain to me the factors that have led to the work remaining unfinished. I offer some hopefully helpful reflections, nudge them to consider a range of other issues, and we look at what happened in previous situations. We both learn, we move on and it’s even possible that the work gets finished.
The second possible direction – and again based on our history – is that the staff member doesn’t even hear the words but focuses exclusively on what they perceive to be my intent. What they hear me saying is “you are lazy aren’t you?” or “what is your excuse this time?” (insert eye roll emoji). They may start throwing out views about why it was impossible in the first place, and may well accuse me of not understanding the situation. You don’t engage in return. I’m not sure if the work ever gets done.
When you think that someone or an institution is shouting at you, when you experience the messenger as not being open to listening to what you say, or when you ‘know’ because of previous experience that they think you are lazy or are even trying to catch you out, you stop engaging properly. We all tell our stories – our whole stories – when someone is really listening to what we have to say and there is a feeling of trust and psychological safety.
No shared understanding
There has been a lot of talk about productivity in the health service, and several excellent reports have been written by many erudite organisations. There is continuing analysis of the size of the productivity problem, exactly the shape of the problem, and possible theories to explain the problem. McKinsey have been appointed to no doubt look more closely at some of these issues. Politicians are clear, as are the Treasury, that they want an answer to why productivity is falling.
They should, because it is. The puzzle of why the NHS is delivering little more activity despite receiving significantly more money and employing many more staff is a critical policy question. The Chancellor argued last week that discussions about productivity are what’s missing from the debate about post-election spending plans. With NHS funding already up, he argued that “the answer isn’t just more money, it has to be about productivity”.
But no study to date has got us very far in reaching a comprehensive shared understanding of this puzzle across all involved. There is ample evidence of a problem, but the questions about why we have this problem and what can be done about it are not sticking. That is the crucial bit of the puzzle. Why aren't all parts of the system, from the Chancellor to the front line, engaged collectively in pursuit of these questions? I would posit it is because the NHS is broadly reacting to this statement of fact (that there’s more money, more staff, yet lower productivity) as a statement of accusation and dismissal of effort and worth. Opinions and tit-for-tat analysis are put forward – some excellently framed and researched, but in-depth, local and national analysis owned by all stakeholders remains elusive.
The language often used just simply doesn’t resonate with many clinicians and managers, most of whom don’t get up in the morning to be “more productive”. They may, however, be motivated by doing that job well. Yet the prevailing narrative means they don’t feel heard and they soon disengage. As Jennifer Dixon and others wrote in 2018, “productivity is a subject guaranteed to kill the attention of clinicians and patients”, and yet we still persist.
Why isn’t there a deeply layered and erudite explanation that sticks, which describes what is going on at a national level and then an understanding within that agreed framework that is differentiated by service and locality? I would suggest it is because, at a very deep level, the health service as an institution doesn’t trust the intent of the messenger. As a result, many NHS leaders and staff go through the motions of looking for productivity continuing to believe they are efficient and actually just misunderstood. The result is a stand-off and no compelling and non-accusatory explanation of what is really going on.
Rather than asking curious and complex questions, people are arguing about the size of the issue, the shape of the issue or actually sometimes still whether there really is an issue at all. Time is being wasted. The NHS doesn’t fully trust the messenger because, despite the prevalent general national narrative that the health service is full of “hero” doctors and “angel” nurses, the underlying intent behind the productivity conversation seems to be – or is at least received as – finger-pointing and a suggestion with a sigh that the NHS is broken, managers are lazy and clinical staff are unfocused on the real issues.
In response, the NHS and its commentators (where they have moved beyond polishing, describing or decrying the problem) continue to outline and research various plausible ideas to explain the productivity issues. The main contenders include it all being about junior staff taking the place of more senior staff, or it’s due to staff sickness and low staff morale, or because the buildings or tech don’t work. Or it may be due to the acuity or complexity of the patient, or that it’s post Covid, or the lack of discretionary effort now being put in by the aforementioned demoralised and sick and junior staff. All of this is plausible. Some of it has been well researched, other parts of it remain theoretical. Nothing has national, systemic consensus.
We need to all continue to do the research on the data that is available to build the convincing national framework for where we are, and which all parties buy in to. This might then develop a clear plan of action as a consequence. None of this is easy, but the need for it is paramount.
What is going to help?
The NHS and its commentators – both political and non-political – seem trapped in a conversation about productivity that is going nowhere. The NHS is feeling told off. Politicians from all parties are feeling annoyed. The Treasury thinks the issue is not being taken seriously. We continue around the same roundabout and emotions run high. It is, I would suggest, deeply unproductive.
Alongside analysis of data nationally, there is a need for a more detailed understanding at a local level. Local leaders are well equipped to collect what philosophers and anthropologists call “thick data” – a term first coined by Gilbert Ryle in 1949 and which means to capture qualitative information such as observations and feelings – to go alongside the productivity data we have. We need to get inside individual services with curiosity and compassion, and see what is really going on from a cultural perspective too. As the philosopher Martin Buber once said, “the only way to learn is by encounter”.
There is some excellent research and some theories still to test. Some of the theories will be more correct for cardiology in Bradford than orthopaedics in North London. There is no one solution to the productivity challenge for the NHS. It’s nuanced, particular and complex. However, we need to be able to rank our theories and see which ones affect more of the services, most of the time. We need a compelling, well-understood and well-evidenced national narrative that brings together national data analysis with the feelings, behaviours and working practices of staff. We do have some excellent analysis of the underinvestment in capital, which may explain some of the figures, but little qualitative, narrative pieces from the front line.
It is urgent that we have the right conversations about productivity in the NHS and that we then do the right research. That will only happen when the NHS experiences the intent of the conversation as one that starts from a position of open curiosity, not one of angry accusation or ideology.
The Nuffield Trust is keen to work with people, organisations and systems who are interested in NHS productivity and the issues raised in this blog. If you would like to do so, please get in touch with us at firstname.lastname@example.org
Stein T (2024) “Why our conversations about productivity in the NHS are not very productive”, Nuffield Trust blog