Failure demand: the hidden work holding back NHS productivity

At a recent NHS Productivity Commission evidence event, Sam Freedman – a policy expert who lives with complex health conditions – described what it can feel like to manage your own care in the NHS. 

'I am a complex case, and I am my own case manager effectively. I have several different related chronic conditions, and I spend a lot of time trying to coordinate between all of them. I also spend an enormous amount of time chasing stuff. I need an MRI at the moment. I have spent hours on the phone trying to get it. I know exactly where it is stuck in the hospital… but I cannot get that box ticked.’                                                                Sam Freedman, What can we learn about productivity from the NHS?

This is 'failure demand' in human terms: work created not by new patient need but because the system has not met an existing need effectively, quickly or with clear ownership. 

A new Strategy Unit report, commissioned by the Health Foundation, asks whether the concept of failure demand can help the NHS understand where effort is being diverted into avoidable work, and how services might work better for patients and staff.

Signals of failure demand

The Strategy Unit report does not treat failure demand as something that can be neatly classified. Instead, it describes four signals that should make us ask where avoidable work is being created.

Across the NHS Productivity Commission’s engagement with policy experts, health system staff and leaders, responses to our call for evidence, and evidence gathering, we heard examples of each.

Operational frustrations are everyday frictions that can create repeat work. Sam Freedman’s example from the patient perspective is all too common. Staff described similar frustrations: a lack of information or communication routes to coordinate care across teams can mean work has to be chased, repeated or done using inefficient workarounds. Our research shows that more than a third of NHS staff believe electronic patient record systems are not working well due to a lack of training or support.

Rule-bound services arise when rules, incentives or entrenched ways of working prevent care from being resolved in the most sensible way. We heard how changing norms and technological advances can generate substantial additional activity, for example by increasing numbers of diagnostic tests done that may provide little patient benefit. Strategy Unit research shows how a dramatic increase in diagnostic tests in A&E can adversely impact patient flow.

Delays and blockages occur when waiting creates further demand. Stakeholders consistently described a cycle in which delays and blockages in care pathways – such as a lack of rehabilitation services or adult social care access – result in patient deterioration, leading to avoidable care, often in acute settings. This is particularly evident in hospitals in England, where more than 13,000 beds are occupied by patients fit to discharge, leading to delayed care for others. 

Disjointed care is especially visible for people with complex needs. Evidence submissions described vulnerable patients with multiple conditions experiencing repeated callouts and attendances because no single service owns or coordinates their care. This reflects wider evidence that a small proportion of patients can account for disproportionate activity, particularly in A&E. Submissions suggest that improving care coordination can better meet this demand, for example through social prescribing or high intensity user programmes.

Why these matter for productivity

Taken together, these examples suggest that a significant share of NHS activity is generated by system design rather than patient need. The Strategy Unit’s report highlights evidence that up to 30% of health care activity may be unnecessary or of low value, although it rightly avoids attributing all of this to failure demand.

Yet current NHS productivity metrics largely focus on activity and, because cost is used as a proxy for value, give greater weight to more expensive interventions. This means an avoidable hospital admission is given more weight than community-based activities that could have prevented the admission, and a longer and more holistic appointment would appear less efficient than more fragmented delivery. 

This raises a fundamental question: could productivity be improved not only by increasing activity – some of which adds limited value – but by reducing unnecessary care, better coordinating services and improving the value of what is already being done? As Hannah Farrar, CEO of health care consultancy CF, noted at one of our evidence events:

‘On average, [diabetics with complex needs] have 14 outpatient appointments a year, not just with diabetes services but across a range of specialties. On top of that, they have 15 primary care appointments, 10 community contacts, and around 53 prescriptions each year… If we organised care differently for those people, we would see a significant reduction in activity for those individuals, and we would be far more productive as a system in how we use our clinical and financial resources.’                                                                    Hannah Farrar, What can we learn about productivity from the NHS?

Rethinking productivity is increasingly critical as the NHS cares for growing numbers of people with complex and multiple conditions – and as it seeks to shift more care into the community. NHS England has noted the shortcomings of current productivity metrics in recognising the value of lower cost care that could be given in place of hospital activity. 

What follows

These learnings suggest two implications for improving NHS productivity.

First, we need to better understand value alongside activity. More appointments, tests or contacts are not always signs of a more productive system. Sometimes they are signs the system failed to meet a patient’s need the first time. Improving the measurement of and accountability for outcomes – including both clinical and patient experience – is critical to help the NHS better understand and increase its productivity.

Second, we must empower staff to act. Anna Parry, Managing Director of the Association of Ambulance Chief Executives, in her blog for the Strategy Unit, calls for a new model in which ‘finding an optimal solution for the patient is the priority and commissioning and delivery models are structured around that’. Many staff recognise failure demand but lack the autonomy to solve its causes, with rules and incentives too often acting against the best interests of both the NHS and its patients. 

‘Failure demand’ is an emotive term, but the challenge is to turn it from a critique into a useful lens – a practical way of identifying avoidable work, understanding why it arises and redesigning services accordingly. This is where a significant opportunity lies to improve productivity.

The recent webinar Failure demand in healthcare – learning from the work that shouldn’t need to happen explored the findings of the Strategy Unit’s report and what they might mean in practice.