Can the NHS improve staff experience of increasing productivity?

My last few posts explored how the NHS needs to work with the grain of staff wishes to work (and live) in different ways. This week we are turning that around.

Whilst it’s true that there have been big changes among staff, there are also big changes in the way the NHS works. So yes, as I have suggested, the NHS needs to change its employment practices to fit in with staff lifestyle wishes, but it’s also the case that staff will have to change the way they work to deliver services.

Earlier this week I argued for a powerful feat of NHS memory, to resurrect the supply of ‘Time to Care’ productivity toolkits. These toolkits embedded the improvement of productivity squarely in the work of staff themselves (nurses carrying out time and motion studies on themselves,) and I argued that since staff have a clearer view of how some of the waste in the NHS can be removed, this would be a great place to start a productivity drive. But it would be naïve to believe that existing staff already have all the ideas that could improve productivity.

(But as a side bar to that – we do need to recognise that there are considerable variations in productivity within existing institutions. Staff in those with higher productivity already work in ways that staff who do not need to learn).

So we could really improve productivity by both helping staff remove some of the waste they can see, and by assisting those driving higher productivity to pass on their expertise. But let’s be clear, over the next few years there will be new ways of working which may dramatically improve productivity.

The recent NHS Planning guidance for 2024/5 has a section on productivity.

We all share the desire to deliver more for patients with the resources that we have. A relentless focus on improvement reducing delays and unnecessary processes will be critical to delivering the priorities of patients and balancing system finances. Key priorities include reducing temporary staffing spend and removing off framework agency use; reducing the delay for patients are who still in hospital beyond the discharge ready date and improving the adoption of and compliance with best value frameworks and contracts. We must also implement more productive and flexible working practices to make the most of the growth in workforce across the NHS in recent years. NHS England will report on productivity and supporting metrics at a national ICB, and trust level starting from the second half of 2024/25.”

(2024/5 Planning guidance page 8.)

Leaving aside the rather odd NHSE house style of that first sentence (I think pretending we all agree about something is an attempt to gain acceptance without undertaking the difficult task of arguing for change.

You could have had a first sentence that said,

 “All NHS staff are working very hard, but since we are going to have to improve productivity, we are all going to have to learn ways of working differently. It means change”.)

But for me the key sentence is,

” We must also implement more productive and flexible working practices to make the most of the growth in workforce across the NHS in recent years.”

Readers will remember that last November I was impressed with the IfG and CIPFA report that argued that over the last four years NHS hospitals had had a19% increase in doctors and a 20% increase in nurses.

This planning guidance says here we are in April 2024 – you’ve had these extra staff for a little while – now it’s time to increase their productivity. So, we could spend the next two years increasing the productivity of those new staff already in post.

And I think that leads us to the big issue about productivity and some early definitional work.

When you increase the number of staff in an organisation it puts increases in productivity at risk. (That doesn’t mean that increases in productivity are impossible BUT increasing numbers makes it harder to get more output per person (it’s the  simple arithmetic of having more people).

I’m pleased that recently it’s been back to basics in defining productivity.

For the first time for quite a few years, in recent months we have seen it pointed out to the NHS that greater productivity is essentially an equation. Productivity improves considerably when you have the same number of staff, and interventions can improve the productivity of each member. For example, by giving them better machinery (technology) to work with.

Sometimes it’s true that you can do something different with the same machinery and improve output per person, but much of the history of the last 200 years has shown that the easiest way of improving productivity is by spending more on machinery whilst retaining the same number of staff to work with it.

Back in the early 19th century the lesson was simple. A thousand handloom workers produced x amount of cloth on their individual looms. They could work a bit better, and perhaps a bit longer, and increase productivity – but there were limits. This might improve productivity by a few percentage points a year.

However, invent a different power source to drive the looms and with the same number of staff you can produce several times as much. Because their labour power is working with machinery it helps the same labour produce more, This improves productivity in the hundreds of percent.

Most modern machinery in health services involves technology. Can that increase productivity? Let’s take one small and important example – a hospital pharmacy. Some hospital pharmacies are now mainly operated by robots (similar to many Amazon distribution centres). The outputs have greater productivity per staff member (and are safer and much faster). That’s important in its own right, BUT if patients are not waiting around for hours for their medications it will also improve other areas of productivity. Patients will be able to get home a lot quicker and delayed discharges are limited.

So, let’s return to that planning guidance,

It could say,

“Over recent years we have set aside money to be spent on more technology. If we had spent that money on technology, it would have had an impact in improving productivity. At some stage towards the end of the year we have snaffled that money to reduce the revenue deficit. Because we have not increased the amount of money on machinery (and we have increased the number of staff) I’m afraid that has meant that productivity as gone down in some locations. We are sorry.

In 2024/5 the Chancellor has given the NHS a sum of money to spend on technology. We promise to spend that money on technology and not revenue. That means that this year, we will add to the amount of technology we are using in the NHS and that will give us a basic condition for improving productivity.”

Over the next few years, we have to increase productivity to speed patient flow through the system. This will require different uses of technology.

Cut the tech budget and we will fail.