Four lessons to improve productivity in the NHS

The latest review of the NHS by Lord Ara Darzi concluded that ‘productivity is too low’ and urgently needs boosting.

Prime Minister Keir Starmer no doubt had this in mind when he warned that there would be no more money for the health system without reform. So what needs to be done?

Recent analysis paints a stark picture of declining productivity. According to the Health Foundation, productivity growth has stalled since 2017, a conclusion echoed by NHS England.

Reversing this decline in productivity is far from easy. Requiring staff to ‘do more with less’ is likely to be counterproductive. After all, 42 per cent of employees already report feeling unwell as a consequence of work-related stress.

Conversely, merely adding extra staff to an inefficient system rarely yields the desired productivity gains. As the Labour Goverment’s new health adviser Paul Corrigan argues, a comprehensive 'rewiring' of the NHS is imperative for achieving meaningful improvement.

How should health systems approach productivity

The productivity dilemma is not merely a question of finance, it represents an ethical and moral dilemma too. People die if they are unable to access high quality care in a timely manner.

But financial constraints mean healthcare providers are once again under pressure to prioritise cost-cutting measures. These risk compromising the quality of care on every level.

It doesn't have to be this way. Using established approaches to improvement in the right culture can improve productivity without compromising on quality or safety.

My research over the past decade has examined how NHS providers employed various approaches to address the productivity dilemma. This work has yielded two clear lessons.

First, quality must be the top priority. Focusing solely on efficiency in pursuit of productivity is insufficient.

The second lesson is that context is crucial. Sustained improvement relies on a thorough assessment of the relationships, mindsets, and behaviours of those involved in and those affected by that change.

By properly addressing these elements, you significantly increase the likelihood of embedding change into routine operations. Providers who heed both these lessons are best positioned to overcome the productivity dilemma.

Why NHS productivity policies must focus on quality

Healthcare productivity increases when resources are effectively used to deliver high-quality care, with smooth patient and information flow. It peaks when care processes are efficient, adaptable to varying demand, and consistently achieve positive health outcomes.

Some NHS trusts have adopted a 'continuous flow model' to boost productivity by swiftly moving patients out of emergency departments.

This is logical in theory, but can backfire. When wards are full, it often results in 'corridor care' which undermines patient care.

High Intensity Theatres (HIT) are another intervention promising to dramatically reduce surgical waiting lists through improved efficiency.

These are not a new concept, Norfolk surgeon John Petri introduced a similar approach in 2006. The idea attracted government attention but was not widely adopted. Reflecting on this in 2007, Petri lamented: "There are no incentives for surgeons to become more efficient."

The effectiveness of HIT in today's context depends on recognising its socio-technical nature. Imran Ahmed, a consultant anaesthetist and deputy clinical director at Guy's and St Thomas, is a leading advocate of the HIT approach. He credits his team's success to fostering a 'sense of occasion' and a shared goal of reducing patient waiting times. Moreover, he emphasises that maintaining team well-being and morale is crucial for success.

Why rolling out quality improvement often fails

Quality improvement in healthcare has a long history, yet many promising innovations fail when replicated.

This often happens because we copy the 'what' without grasping the 'why'. Social and cultural factors play a crucial role in fostering or impeding change. National directives often ignore the context in which changes occur. This results in unpredictable outcomes across different settings.

Sarah Jane Marsh, Deputy Chief Operating Officer for NHS England, recently urged the NHS to "flex its operational muscle" to improve care. To do so, we must recognise that technical interventions don't exist in a vacuum. Their success hinges on how well they align with the social fabric of each healthcare environment.

Understanding this interplay between technical solutions and social context is key to driving lasting, meaningful improvements in healthcare delivery.

For example, recent studies have underscored the importance of fostering social connections, particularly among multi-disciplinary staff members.

The evaluation of the PROMPT safety training in maternity units showed that practices that developed social relationships and a sense of interdependence between staff improved effectiveness.

How networking can help NHS staff increase productivity

Similarly, the evaluation of the NHS-VMI partnership showed that the best organisations had strong social connections across professions.

Routine practices that brought people together regularly created the opportunity for informal talk and social cohesion.

Physical (or virtual) spaces also play a crucial role in fostering collaboration. The PROMPT evaluation found that a shared staff room helped to break down traditional notions of status between doctors, midwives, and other staff. It also blurred work-social boundaries and fostered collective competence.

The 'Big Room' concept offers a more formal approach to focusing multi-disciplinary teams on improvement efforts.

To conclude, supporting workforce wellbeing and fostering multi-disciplinary relationships are key to positive change. The vital role of relational infrastructure in improving productivity is gaining recognition across disciplines, including economics.

Prioritising human elements alongside quality and improvement can create a foundation for sustained, system-wide change in health and care, ultimately enhancing overall productivity.

Solving the productivity dilemma – lessons for policy and practice

1)  Prioritise workforce wellbeing. The productivity challenge is a people challenge. Give consideration to improving all aspects of working conditions.

As Dixon-Woods and colleagues make clear, the future of the NHS depends on the people who work in it.

2)   Focus policy objectives on quality. Policy objectives should prioritise quality.

Quality is the foundation for sustainable improvement in healthcare outcomes, not just a metric. This clear and simple approach aligns all aspects of healthcare towards a common goal: excellence in patient care.

3)   Improving productivity demands a socio-technical approach. Interventions that promise to improve efficiency and performance require careful evaluation.

This is essential to understand the interplay between a technical intervention and its social context before it is rolled out more widely.

4)   Foster multi-disciplinary teams and collaborative spaces. Improvement methodologies thrive when diverse teams regularly convene to learn and innovate together. Healthcare leaders should prioritise accessible, relational spaces - both physical and digital - that strengthen working relationships.

This approach allows improvements to be implemented effectively. It also creates an environment where multi-disciplinary teams can excel in their day-to-day work.

This article is adapted from an article published by The Health Foundation.

Further reading:

Demonstrating the value of continuous improvement

Measure performance improvement: In search of the golden thread

Hold each to account for behaviours, not just outcomes

Seven leadership lessons to prepare the NHS for another 75 years

Nicola Burgess is a Visiting Professor at Warwick Business School and Professor of Operations Management at The University of York. She is a Senior Visiting Fellow at the Health Foundation.

Discover more about Healthcare and Wellbeing by signing up to Core Insights.