Q. When is a front-page news story not really news? A. When it is about the NHS discovering that its productivity has dropped.

Last Friday’s main story in the Times told us many things that we already knew.

First, that there are real problems with productivity in the NHS.

“Julian Kelly, the NHS finance director, has acknowledged that productivity is ‘still lower than it was pre-pandemic’ …. hospitals are 11% less productive than before COVID.”

Second, that some of this is due to problems of patient flow to and from the hospital.

Third, that there has been an increase in the numbers of clinicians in hospitals.

And fourth, that many of those clinicians are young.

So why am I posting about it?

In the wonderful world of spin often it is not the content of the story that is news. What is more important is who has placed the story, and why.[1]

This story was clearly planted[2] by NHSE itself.

Why would they do this? Why create a major article in the Times saying that the NHS is failing on productivity? Why would they want to run a story saying that they are bad at something?

The fact is that the NHSE is placing this story is a recognition that the game is up. NHS requests for more money won’t get anywhere when the people they are asking to give it to them know they have had an increase in hospital staff, but no increase in output.

The process goes something like this,

The NHS says,

·      To reduce waiting times you will have to give us more money.

·      We will spend that money on more staff.

·      They will do more work.

·      That will reduce the numbers on waiting lists.

(And seeing how this has worked in previous years this approach doesn’t sound completely daft).

But this time the response has been,

“There is no evidence that this process will deliver a reduction in waiting lists if we giveu you more money. You recently added 19% more hospital doctors and 20% extra nurses but i has dropped by 11%.”

So whilst the fact that NHSE has placed a story about its own failings is a public acknowledgement of failure, it also signals the beginning of a new process – that of gaining public recognition that the NHSE needs to play a big role in tackling the problem.

As the Institute for Fiscal Studies (quoted in the article) says” it was good they are moving out of the denial stage… NHS leaders are changing their tune on productivity”

And I agree this is nothing but a good thing. It gives all of us with the future of the NHS at heart a fillip.

Now of course the hard work to ratchet up productivity begins. The planted story gives some strong clues about what needs to be done – and perhaps how.

The main problem identified n the article is NHSE’s relationship with social care,

“…hospitals are struggling to treat more people despite higher funding and extra staff because thousands more patients are stranded on wards with nowhere to go.” an internal review has concluded.

“The most comprehensive internal study of NHS efficiency has caused health chiefs to accept they do have a problem whilst promising to improve. However NHS bosses also believe that about half of its productivity problem is beyond its control. The teetering social care system makes it much harder to free up beds while an older, sicker population requires more care”.

“…It concluded the numbers stuck in hospital for more than three weeks has risen 15% on pre-COVID levels.”

This new 2024 report has uncovered the fact that there is a problem in the relationship between social care and hospital admissions and discharges.

If only someone, a decade ago, had had the foresight to create a fund to deal with this relationship we could have improved it.

But wait!

In 2015 NHSE created the Better Care Fund. So this is not in fact a new understanding of the problem.

Let’s have a look at what the NHSE website.has to say,

“About the Better Care Fund

One of the most ambitious programmes ever introduced across the NHS and local government. The BCF encourages integration by requiring integrated care systems and local authorities to enter into pooled budget arrangements and agree an integrated spending plan”.

and,

Launched in in 2015 .. BCF aims at reducing the barriers often created by separate funding streams (About the BCF).

Here we are in 2024 with NHSE saying that 50% of the hospital NHS productivity problem concerns its relationship with social care. That’s 50% of the productivity problem of about £140 billion of public spend, and apparently, despite what appears in the Times, this is NOT a new problem. It was recognised as a problem a decade ago and has simply got worse.

Let’s try and solve this problem with another “if only”.

If only someone had set up an integrative sub-regional structure between local government and the NHS. If only this had been given the remit to integrate the social care and hospital services. If only these organisations were called Integrated Care Boards.

Hang on, that all sounds familiar…don’t they already exist?

Why yes, they do, but having set them up, have NHSE been helping them to carry out this apparently essential integrative function or have they been “performance managing” them on their acute NHS spend and their acute waiting lists?

Now we find (and let’s be honest – it’s not a new finding) that both the money spend and the waiting lists actually need integration with social care in order to work; that the acute hospitals on their own are completely vulnerable to the work of organisation’s outside of them; and that, as of last Friday’s Times, NHSE thinks that 50% of the productivity problem is caused by failures in these social care relationships.

Beyond the sarcasm my point is that I think we have known this for a while (not just since last Friday). Given that, why hasn’t NHSE leadership realised that managing those social care/hospital relationships is crucial to the future of the NHS?

Just mentioning it in the Times won’t solve the problem. If the future of the NHS needs a better relationship with social care (and I think that it does) then let’s have some humility in building it. Very few Directors of Adult Social Services that I talk to think partnering with the NHS is fruitful. Many find it impossible. Since apparently we need social care to thrive I would suggest that a better practical relationship  may be one of the most important issues to work on – right now.

But the Times/NHSE splash offers another reason for the low productivity of the new hospital staff.

“Although staff numbers are up this has been driven by a rise in inexperienced junior staff whilst older more knowledgeable doctors and nurses have left the system. Bosses believe this has worsened productivity and are now planning a training and management blitz to help them improve.”

Last August CIPFA and the IfG published their annual review of public services (and like you I am really looking forward to reading this year’s whilst on holiday). They commented on the age issue then. In May 2024 this is not news.

But to a much bigger point. When these staff were appointed hospital trusts would have noticed their age.

Date of birth is usually pretty near the top of every application form and you might just notice, looking across the interview table, that the people you send the offers of appointment too are …well, younger. During four years of increasing your clinical staff by 20% you will have done this often. And seen that they are nearly all young.

I raise this point because it really can’t be news to the trusts that have appointed all these people that they are younger. So for this to only be discovered in May 2024 is a bit odd.

I am really pleased (genuinely) that there is now going to be a training and managements blitz to help these younger people improve their productivity, but you have to ask yourself why it wasn’t done when they were appointed.

Towards the end of the Time article it says,

“NHS leaders accept they need to show they are addressing their own problems before pressing for more cash”.

And I am genuinely pleased that they are.

BUT there is nothing new in the problems that are now recognised as causing low productivity. Let’s hope that in the next few months the relationships with social care become genuine, and let’s hope the management ‘blitz’ to help younger staff works.

Because in the next year we are really going to need that increase in productivity.

[1] Between 2001-7 I sat in the same room with some of the best media spinners the country has even seen and you can’t help but pick up an appreciation of the skills of the people doing that job.

[2] All the signs are there ‘A health source’ being where it all comes from but then direct and personal quotes from Julian Kelly as NHSE CFO.

One Reply to “Q. When is a front-page news story not really news? A. When it is about the NHS discovering that its productivity has dropped.”

  1. I am a Consultant Anaesthetist. I started my training in anaesthetics in the great MTAS shake up of 2007 when I became an ST2. I’ve also done a bit of work on productivity and more recently safety.

    We have a huge productivity problem in theatres, which are one of the most heinously expensive parts of the system. We are as far from a well oiled team as it is possible to be. There are many reasons why this is so, but one of the biggest is not theatres, it is logistics. We simply cannot get our patients to theatre. The ‘sending time’ – the time it takes to get a patient to theatre, is highly variable. This means that if you send to early you end up with a patient arriving and sitting in an anaesthetic room, and if you send to late you end up with fallow theatre time. This is not really a healthcare problem. It is a logistics problem. I have recently had 3 wards tell me they do not have the staff to bring the patient to theatre. Maybe we need to re-examine the whole ‘sending’ process.

    We change list orders on the morning of surgery because equipment is not available. The wards or admission areas have got the first patient ready, and then we decide in theatres to have a different patient. We often change patients because the list order has been decided by a non-clinical administrator, not taking into account the type 1 diabetic or child with additional needs that should go first. Nobody seems to know who has responsibility for anything. How can wards get patients ready if they do not know which ones to get ready?

    Patients are on increasingly complex drugs. Often drugs that are great for their condition, DOACs and gliflozins are good examples, but which require careful perioperative management, which can be overlooked. Again, more on the day cancellation, postponement or input required to make decisions that should have been made weeks upstream,

    The way we run emergency and trauma lists is baffling. Every day feels like a surprise, when there are cases from the day before which could have been prepped and good to go.

    Inexperienced staff are a large part of this, They have safety drilled into them and the myriad of checks are done for the most part quite poorly, and people speak over each other carrying out other tasks. This is to the detriment of safety and the other tasks. Senior leadership is often in budget meetings. I cannot recall the last time I saw our theatre manager in theatres.

    More senior clinicians are not always helpful either. Particularly for the general emergency and trauma lists where we seem to find lap choles for the upper GI surgeons and ankles for the ankle surgeons. But the bog standard fractured hip hemiarthroplasties do not get done. Even there we have an issue because with the move towards total hip replacements we need specialist hip surgeons.

    Training experience for surgeons and anaesthetists has tumbled. We struggle to get 3 hips done in a day. 4 can be done but it’ll mean a late finish (again). This drives down morale. We need to be honest about managing very senior Consultants who are simply not delivering, and also work out how to support newly CCTd Consultants who do not have the experience, and frame that around productivity, whilst at the same time maintaining safety. No easy task.

    Do we get a lot right, absolutely. But has productivity plummeted over not just the last 5 years, but the last 15. Would more money fix this, possibly but I suspect not because of the tax issues.

    Waiting lists are not going to be done for discretionary overtime where there is a 62% take from the state. My taxable income is now approaching 100k after the recent pay rise. So if I do an extra weekend list, even for £1500, I am giving 62% of that straight back to the government. Many people right balk at that. Even worse if you have childcare and lose it.

    There is layer upon layer of tax, pay, morale, teamwork and safety tweaks that over the years have slowly choked the system. When it goes right it is a wonderful thing to be part of. Such feelings are getting rarer and rarer.

    Finally I do not think more staff is the answer. We seem to have too many people around already. We need less people getting in the way, not more.

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