We asked how the NHS can boost productivity: here’s what we heard

Productivity is a polarising term in the NHS. In a stretched system, it carries unwelcome connotations of being asked to do more work with the same – or fewer – resources. 

It is unsurprising, then, that the productivity ‘agenda’ is viewed with caution, even resentment; as something imposed on the service rather than shaped by those who deliver and use it. 

The NHS Productivity Commission seeks to reset the conversation. It aims to generate evidence and solutions to drive long-term productivity growth in the NHS in England.

Through our recent public call for evidence, we invited a wide range of stakeholders to share their insights, ideas and expertise on the productivity challenge and how it could be tackled. 

We were delighted to receive over 120 responses from individuals and organisations. These revealed a system under considerable strain yet eager to engage with solutions. Here’s a snapshot of what we heard.

Measuring productivity and defining value 

What do we mean by productivity? This is a question the Commission has been asked frequently since it was set up last year. 

We began to set out our approach to productivity in our first report, From diagnosis to delivery. In this, we explored the importance of looking beyond technical efficiency – how inputs are translated into outputs – to wider health outcomes. We define system productivity as the health care value created for every pound invested.

The call for evidence has powerfully shown that how productivity is captured must also form the bedrock of our recommendations.  

We heard that current definitions and metrics are too narrow to drive the right behaviour and may even create disincentives. When productivity is measured primarily as activity or throughput – ie the number of appointments, procedures or contacts – volume becomes the stand-in for value. Respondents were critical of this, noting that greater volumes of activity don’t necessarily deliver better care or improved patient outcomes. Instead, participants suggested ways to measure productivity better, including through capturing patient experience and health outcomes.

To gauge the extent to which the NHS is delivering value, however, there needs to be a shared understanding of what the NHS is seeking to achieve. 

The absence of a ‘North Star’ or shared system-wide priority for the health service – one understood by all stakeholders, from national bodies and NHS providers to staff and patients – was a common theme. For some, this overarching priority should be to promote prevention rather than just treat sickness. Others suggested there needed to be an honest public debate about what the NHS can provide with its current funding.

Ideas for change from the frontline

Defining the NHS’s core purpose might seem like a high-level ambition. But respondents were not short of ideas on how productivity could be owned and improved from the ‘bottom-up’ or the frontline. 

Submissions showed that productivity is not only a system-level challenge that needs top-down solutions, but a problem lived and experienced across different professions, pathways and patient groups.

We heard a myriad of proposals for – and case studies of – initiatives, interventions and technologies to improve ways of working and care pathways. These included a greater role for the voluntary and community sector in supporting digital inclusion and proposals for more proactive management of staff sickness absence. 

NHS staff were the largest group of individual respondents, and professional or representative bodies (such as royal colleges) were the largest group of organisational participants. Their submissions provided in-depth insights into how the productivity problem and possible solutions are approached by those working in different clinical and non-clinical roles across the health system and beyond.

A major theme was the need for more effective workforce planning, including making better use of the skills of existing staff. We heard how capacity could be freed up by using the capabilities of allied health professionals and clinicians working in primary and community care (for example, by expanding optometry-led urgent and emergency eye care nationally). 

We also heard how a high administrative workload and routine tasks are taking clinicians away from delivering care at the top of their skillset. 

Low staff morale was, unsurprisingly, a major theme. Respondents highlighted how toxic the productivity agenda can seem. If interpreted as suggesting staff should work harder with less, it risks deterring people from the wider debate. 

On the other hand, we heard how working in a non-productive system can create a negative working environment and contribute to burnout. 

Respondents described the frustration of working in an NHS that seems distinctly ‘un-modern’, where time is lost to navigating multiple digital systems or responding to reporting requirements, thereby reducing clinical capacity and shifting care towards being task-focused rather than holistic. 

They described toxic workplace cultures, poor leadership and a persistent fear of blame and litigation. 

Driving more effective ways of working could not only boost productivity but enhance job quality and retention.

System and organisational capabilities  

Respondents described many of these problems as cultural and long-standing but also highlighted simple, attainable changes that could make a difference. 

While respondents clearly called for stronger and more effective leadership, productivity was not treated solely as the responsibility of senior leaders. Instead, it was framed as a shared responsibility across the health system.

Many respondents spoke about the cultural changes and system capabilities needed for a more productive NHS. We heard how the NHS could be freed from a bureaucratic, risk-averse and compliance-based culture to become a more autonomous, empowering and productive place to work. 

Respondents described how the NHS could capitalise more on learning from other disciplines or approaches – such as systems thinking, health care science and supply chain management – and how it could better prioritise progress on patient-centred care, prevention and environmental sustainability. 

Our next steps

The Commission’s focus is on improving productivity at a system level. The call for evidence submissions revealed enthusiasm to engage and demonstrated considerable insights on productivity across stakeholder groups, including exciting ideas to drive transformational change. The challenge is how to create the infrastructure and culture that will enable that to happen. 

In the coming months, we’ll be drawing on these insights and our wider research and stakeholder engagement to develop a series of policy options papers and an overarching roadmap. Together, these publications will set out how this vision of a pro-productivity NHS can become a reality. 

The Commission will be sharing some of the specific proposals and recommendations we heard from the call for evidence. Follow #NHSProductivityCommission on LinkedIn for more updates.