NHS productivity lags as recruitment fails to keep up with demand

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The NHS in England faces an uphill struggle to improve productivity as it grapples with record waiting lists, with data suggesting that an increase in staff numbers alone will not transform its performance.

Creaky infrastructure, a sicker population and reliance on less experienced staff are hampering the health service’s attempts to treat more people than before the pandemic, according to health experts.

This difficult environment is casting a shadow over the government’s goal of reducing hospital waiting lists by the next elections. Health is consistently a top concern for Britons, surpassed only by the state of the economy.

Health service problems are often attributed to a lack of workforce planning, which has led to a severe shortage of local nurses and doctors. Nearly one in 10 NHS posts are currently vacant; A much delayed NHS workforce strategy, the first for 20 years, is expected in the coming weeks.

However, an analysis of data from the Financial Times suggests that more staff alone won’t change its trajectory.

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Building on research conducted by the Institute for Fiscal Studies think tank last year, the FT found that the NHS in England has 11% more nurses, 10% more consultants and 16% more more junior doctors than before the pandemic, even after adjusting for higher staff sick leave rates. The number of nurses increased by just 3% between 2010 and 2019.

The NHS also carried out 9% fewer emergency admissions, 5% fewer outpatient appointments and 11% fewer elective and maternity admissions in March 2023 compared to the same month in 2019.

The number of accidents recorded by ambulance services was 5% lower in April 2023 than in April 2019, despite 35% more 999 calls.

Ben ZarankoIFS senior research economist, said the number of GP and early cancer appointments had increased since before the pandemic, but fewer patients were being treated in many categories.

However “it wasn’t obvious” that the number of frontline personnel was “the binding constraint”, he said.

He added that if the debate focused on staffing numbers, with politicians promising specific raises of nurses or doctors, ‘we may overlook things like investment in [NHS] real estate or management systems or simply making the NHS a better employer”.

“If you put more and more frontline staff into a system that’s not working well, it’s not obvious that you’ll get better results.”

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In 2020-21, at the height of the Covid crisis, healthcare productivity fell by around 25% in England, the most recent data from the Office for National Statistics suggests. The period included a large spending infusion to fund coronavirus testing and vaccination programs.

Charles Tallack, head of data analytics for the Health Foundation, a research organization, cautioned that the headline’s productivity measures don’t necessarily capture all the activities that have improved patients’ lives.

He pointed to “really effective preventative interventions that keep people from going to hospital,” but “come across as less going out to hospitals.”

However, wider strains on the health system caused by years of underfunding were preventing NHS staff from being as productive as they would have liked, he acknowledged.

Research by the Health Foundation has shown that the value of capital assets in NHS trusts has increased by 4% since 2010-11. At the same time, the workforce increased by 26%.

This meant a 17% drop in the value of capital per worker from 2010-11. Tallack cited ambulance paramedics who were forced to stay out of hospitals with their patients for hours, for lack of an available bed.

“This has nothing to do with how hard the paramedics are working,” but “a consequence of the lockdown in hospitals,” he added.

Icaro Rebolledo, chief economist at the Health Foundation’s Real Center, suggested that the change in the composition of the workforce was a significant factor. Since 2018, junior doctors had increased more than any other category.

“So you have a staff mix that is now more biased towards younger staff members, who can therefore do less,” he said. In recent years, she added, there has been much more ‘dropout’ in the NHS ranks.

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Matthew Taylor, NHS Confederation Chief Executive, speaking for frontline executives, stressed the need for better resources for staff.

“A large company keen to boost its productivity would like to invest in technology and capital more generally,” he said, pointing to the NHS’s £10.2bn repairs and maintenance backlog. The UK has lagged significantly behind other peer countries in its level of capital spending, she noted.

“It’s just common sense that an organization that is starved of capital investment will have a hard time making productivity gains.”

Staff reported that patients appeared to be in worse health than before the pandemic. “We don’t know enough, but there seems to be an increasingly complex disease in the community,” Taylor added.

The key question for ministers as much as for NHS leaders is whether the health service can reduce long queues for treatment before a general election next year.

Zaranko of the IFS noted some “encouraging signs” that despite a wave of industrial action, which since December has reduced the number of operations and appointments that the NHS has been able to carry out, “processing volumes and lists of waiting they are going in the right direction direction”.

Hospitals were becoming more adept at providing emergency care and routine operations at different sites to avoid cancellation of non-urgent care and adjust rosters to cope with the effect of higher staff illness levels.

But about 8 million fewer episodes of waiting-list treatment were done during the first two years of the pandemic than would have been expected pre-Covid, he said, and it was unclear what the impact would be at long-term failure of this assistance to be.

Whilst it was ‘within the likelihood’ that the NHS would meet the Government’s targets, ‘they were challenging when they were set [and] I would say they are probably even more challenging now,” he added.

The Department of Health and Social Care said cutting waiting lists was one of the government’s top five priorities and the NHS has reduced the number of patients waiting longer than 18 months by more than 90 % since the September 2021 peak and has virtually eliminated two-year waits for treatment.

She added: “There are record numbers of registered doctors, nurses, midwives and nursing assistants in the UK and we will soon be releasing a long-term workforce plan focusing on recruiting and re-skilling more staff.”

The NHS said: “Although this analysis does not cover emergency room, diagnostics or other hospital activities, the NHS is treating more patients than before the pandemic and despite industrial action and the most intense winter on record, staff have treated 400,000 more people in the first three months of this year than last year.