It is no secret that the NHS is facing a productivity crisis. While the Covid-19 pandemic is no longer shutting down normal operations, the hangover of patients who missed treatment during the nearly two years of lockdown has lingered, and been compounded by the subsequent staffing crisis, ageing population and increased disease burden. The recently published NHS Long Term Workforce Plan (LTWP) set out lofty goals for productivity improvements over the next 10-15 years – but how they will be achieved is yet to be seen.
The 2024 Spring Budget set aside ringfenced funding for digital tools to improve productivity – however, their potential for actualised improvements to productivity has been debated – as has the reality of productivity improvements in a service struggling with chronic and record vacancies.
So, how realistic are the productivity goals set out in the LTWP, and how will we ever meet them?
The current state of play
It is useful to first review the state of the NHS, to understand the chronic issues that have led to the current need for improved productivity.
While the NHS workforce is now larger than at any other point in history, so too is the population it serves. Proportionally, clinical staffing in the NHS has not kept pace with the growth of the general population. Compared to an OECD average of 3.7 doctors per thousand people, the UK now has 2.4 doctors per 1,000 people – and with a population that is ageing, and increasingly presenting with more complex conditions, it is no surprise the service is underwater.
In addition to years of ‘inadequate planning and chronic under-resourcing’, the NHS is now competing with a more accessible and attractive international market. The past two years have seen an increase in the number of clinicians leaving for Australia, New Zealand and the US in search of improved pay and working conditions. Under-funding has meant that NHS salaries have not kept pace with inflation, triggering a series of strikes over the past 12 months that have added massive financial burden to an already overstretched service. Ironically, the cost of the strikes has now exceeded the cost of raising salaries according to inflation. There is also an upwards trend in doctors retiring early – possibly due to the stress of working throughout the pandemic. 13% of secondary care doctors and 18% of GPs will be reaching minimum retirement age over the next ten years, representing another significant loss of clinical manpower.
The service has struggled with digital infrastructure historically, with trusts still regularly using outdated and almost obsolete technology, and transformation is often painfully slow. Despite a planned phasing out of fax machines by 2020, 600 were still being used in 2023. The often fragmented rollout of new technologies has also left NHS organisations in increasingly disparate stages of digital maturity, stifling inter-organisation communication and hindering administrative processes. While a ringfenced budget for digital improvements is crucial to levelling up digital maturity and improving processes across the NHS, the groundwork has yet to be put in place.
The 2024 Spring Budget: NHS Digital and Productivity
The 2024 Spring Budget set out to ‘transform the NHS digitally’, with £3.4bn being set aside for digital productivity drivers, namely AI tools. Though these do have potential to improve diagnostic waiting times, and clinical capacity, there is little optimism about their actual impact. A 2020 review of previous attempts at digital transformation by the National Audit Office concluded that they had been ‘expensive and largely unsuccessful’, and that lessons from previous transformation attempts had been missed. It seems this attempt at digital transformation is doomed to fail, rolling out over a fragmented NHS with individual organisations sitting at drastically different digital maturity stages.
With this in mind, the potential for technology to significantly drive productivity improvements seems limited. The value of quicker diagnostics is also somewhat lost in an NHS that is already struggling to treat the cohort of patients who have received diagnosis, with 10,000 patients waiting over two months from referral to treatment as of January 2024.
While faster diagnosis has great potential to improve patient outcomes, if the NHS does not have the clinical capacity to treat patients post-diagnosis, patient outcomes will not be improved significantly.
While the Spring Budget focuses more on AI diagnostic tools, and upgrading existing technology, the appetite among clinical staff leans more towards administrative and communication tools. The Health Foundation commissioned a review of the current usage of digital technology in the NHS, their current time saving impacts and clinicians’ views on the best technological investments – clinicians overwhelmingly expressed the desire for technology to speed up administrative processes. The study found that EHRs (Electronic Health Records), videoconferencing for internal communication, and digital messaging tools are the most widespread in the service. These technologies also came out on top in terms of time savings as judged by clinicians and are likely to offer the most benefit in terms of time savings for frontline staff – though these have attracted ‘significantly less policy discourse’. This is indicative of a historic gap between clinicians and policy makers – one that will need to be bridged if digital technology is to significantly boost productivity on the front lines.
Workforce Productivity
Arguably the biggest driver of productivity in any workforce is the manpower. While it is essential that the workforce is equipped with adequate tools to complete their work, it is also essential that there are enough staff to share workloads, with the right skill mix. The NHS workforce has been lacking adequate manpower since its inception – though there are more staff currently employed in the service than ever before, there is also a larger patient population with increasingly complex care needs – meaning demand for care has far outstripped supply of clinical staff.
In addition to inadequate staffing, the current workforce of the NHS is experiencing burnout at unprecedented rates. The Covid-19 pandemic put a strain on healthcare systems and healthcare workers around the world, not least in the NHS. While the current burnout experienced by NHS staff is the sum of more parts than Covid, the pandemic was, understandably, a major driver for it, and clinical staff do not seem to have fully recovered. Post-pandemic, the NHS is seeing an increased number of sick days being taken, especially those due to stress, and increased leavers citing poor working conditions and inadequate pay . This has also manifested in a consistent 12 months of sustained industrial action. Taking into account sick days and strike days, the NHS lost the equivalent of 227 million working days last in 2022, with similar sickness rates reported in 2023. At least some of these absences can be attributed directly to burnout and reactions to the current working conditions in the service.
Asking a workforce already experiencing burnout and historic vacancy rates to improve productivity isn’t realistic – instead, focus needs to be placed on nurturing and attracting staff. Retaining experienced staff is crucial to improving productivity, as replacing staff unavoidably involves losing knowledge, and retraining new staff members involves a bigger investment of time and finances.
For workforce productivity to improve, so must capacity. Hospitals were running close to 100% capacity before the pandemic, and once that capacity was hit – and eventually exceeded – backlogs built up, creating more pressure on struggling services. Patients now find themselves in hospital for longer than medically necessary due to a lack of safe discharge options, or eventually present with more complex care needs due to long delays in appointments. The result is more clinicians’ time being taken up by patients who no longer require medical attention, or patients present with more complex conditions that could have been prevented or mitigated had they been treated earlier.
While there is no easy way to fill vacancies and improve physical capacity, as well as social care services to allow patients to be discharged as soon as possible, productivity cannot be improved any other way. The Long Term Workforce Plan released last summer promises to ringfence funding and improve retention, recruitment and training, which is a promising start. However, the plan won’t have dramatic impacts for at least the next 5 years. Needless to say, the NHS cannot wait that long. Ethical international recruitment to bolster staff numbers, reduce pressure on existing staff and increase clinical capacity remains the only short-to-medium term option to genuinely increase workforce productivity.
The productivity goals set out in the Long Term Workforce Plan provided an ambitious guideline for where the Government expects to see the NHS over the next 10-15 years. These goals can only be met by improving recruitment, retention and technology in the NHS – three areas that have seen ringfenced funding allocated to them in the past year. While this is encouraging, more immediate fixes are needed to improve productivity, and therefore patient outcomes, in the meantime. While digital transformation can have a significant impact on productivity, the biggest pioneer for NHS productivity is the workforce. Without workforce recovery and a long term workforce strategy based on placing clinicians on permanent contracts, NHS productivity is impossible to recover.
Remedium have supported over 100 NHS Trusts recruit skilled and experienced clinicians, on a permanent contract basis. Find out more about our services here. For more insights, read our White Paper, ‘Towards a Sustainable and Robust NHS Workforce’, here.
