There is no doubt that the pandemic brought with it significant disruption and exacerbated many of the challenges that the NHS was already facing. Figures from the Office for National Statistics show that quality-adjusted healthcare productivity was 6.6% lower over the 2021/22 financial year than the 2019/20 financial year (ONS, 2024a). Further analysis from the Institute for Fiscal Studies shows that the NHS has significantly more staff than it did before the pandemic; however, growth in activity levels has been disproportionately slower (Warner & Zaranko, 2023). NHS England's own estimation of the acute sector productivity gap is approximately 11% lower than pre-pandemic levels (NHS England, 2024b). Earlier this year, NHS England published its 2024/25 priorities and operational planning guidance which set out the ambition for the health service to have a "relentless focus on improvement, reducing delays and unnecessary processes" in an effort to recover productivity back to pre-pandemic levels (NHS England, 2024a). Trust leaders are focused on delivering optimal value for patients and welcome NHS England’s directive that "recovering productivity is categorically not about staff working harder" (NHS England, 2023a).
Trusts are firmly focused on improving their productivity levels within a challenging financial and operational context. They are making notable progress in some areas, including reducing the number of long waiters across elective care and in diagnostics, with 2.2 million diagnostic tests carried out in March 2024 (14% higher than pre-pandemic levels) (NHS England, 2024c). However, the overall picture suggests trusts are facing significant difficulties in delivering key operational priorities. The elective waiting list continues to hover around 7.5 million people and urgent and emergency care departments continue to experience real pressure with 2.3 million A&E attendances in March 2024 alone – the highest level ever recorded (NHS England, 2024d). Ambulance demand remains considerably higher than pre-pandemic levels, with the number of category 1 incidents being 39% higher than the equivalent period in 2019. Significant challenges remain across the community and mental health sectors as well; over one million people are on the waiting list for community services and mental health referrals were 46.7% higher in March 2024 than in March 2020 (NHS England, 2024e) (NHS England, 2024f). The operational performance data demonstrates the intense pressure on services across all sectors.
As well as these operational concerns, trust leaders identified a number of barriers in our Stretched to the Limit report that were preventing them from accelerating productivity growth (NHS Providers, 2023). One of the biggest challenges identified by trust leaders is staff exhaustion, burnout and low morale – evidenced by the NHS staff survey results which show 42.7% of staff often or always feel worn out at the end of their shift and 30.4% feel burnt out because of their work (NHS England, 2024g). While it is difficult to quantify the effect of burnout and low morale on NHS productivity levels, it would be fair to assume that a tired and pressurised workforce is not conducive to increased productivity growth. Further pressure on the workforce can be seen through increased spending on temporary staffing support, high vacancy rates (more than 100,000 across the NHS) and a sustained period of industrial action from a number of different staff groups, all of which have constrained activity growth, damaged staff morale and stretched trusts' budgets (NHS England, 2024h). Trust leaders have also highlighted that they are seeing a sustained increase in patient acuity since the pandemic, often seeing patients who are sicker and presenting with more complex conditions, requiring more resources and staff time to deliver their care. All of the above equates to an incredibly challenging picture for the NHS and a complex environment within which to nurture sustained productivity growth.
In March's Spring Budget the government announced an additional £3.4bn of funding on digital transformation over three years from 2025/26 to unlock a proposed £35bn in cumulative productivity savings before 2030 (HM Treasury, 2024). In return for this investment, NHS England committed to publishing an NHS productivity plan and metrics in summer 2024 and achieving 1.9% average productivity growth in the period to 2029/30. This target is at the upper end of the 1.5% – 2% ambition over 15 years as set out in the NHS Long Term Workforce Plan in 2023 and would represent a substantial increase on historical NHS productivity growth (NHS England, 2023a). Trust leaders are hopeful that the productivity metrics will help support all types of trust to enhance their understanding of their productivity levels, benchmark with similar organisations and identify areas for improvement. Current productivity metrics use the 'weighted activity unit' which measures hospital output, while adjusting for differences in case mix. However, this metric is not easily translated to community and mental health trusts. Furthermore, the limited benchmarking available for these sectors' activity and cost bases makes it a considerable challenge to accurately measure trusts' productivity levels. If national productivity metrics are to be applicable across all sectors and a common currency for productivity metrics is established, then it is vital that the scale and quality of data available for community and mental health trusts is improved.
This report looks at a number of case studies which highlight the success some trusts have had in developing local initiatives to improve their productivity and, as part of this, patient care. Clinical leaders from across the NHS have outlined how using a framework for continuous improvement can deliver better value, both financially and operationally, and act as a lever for productive efficiency. The key themes explored include:
- Taking a holistic approach to improving productivity – Prioritising improvements to patient care also pays dividends for improving productivity. Central London Community Healthcare NHS Trust (CLCH) has taken a value-based approach to productivity which looks at how resources can be best utilised to improve outcomes for patients. CLCH has implemented a variety of pilots which have achieved better outcomes for patients as well as opening up the capacity across their community nursing teams.
- Collaborating to tackle shared challenges – The mutual aid scheme across the Foundation Group and the efficiency of South Warwickshire University NHS Foundation Trust's surgical hub has provided significant productivity benefits and enabled patients waiting across the wider region to be seen much faster than before. Tighter collaboration between trusts across systems and regions has improved data-sharing and benchmarking across trust networks, enabling best practice to be shared and implemented widely.
- Digital tools to free up staff time – Oxleas NHS Foundation Trust has focused its efforts on ensuring its staff have the right tools to work in the most effective way possible. The trust has rolled out a series of digital tools designed to give patients more control and choice over their care, and simultaneously allow staff to spend more time on delivering care rather than on administrative processes.
- Improving whole-system productivity – North West Ambulance Service NHS Trust (NWAS) has implemented a number of local measures which may not provide immediate benefits to the trust's own productivity. However, both initiatives have made a significant difference in improving the productivity of the wider health system. Local measures designed and developed by NWAS have enabled patients to get the right level of care much sooner, taking pressure off emergency departments and the
wider health system. This case study highlights why it is important to adopt a whole-system approach to productivity – as costs incurred by one trust, may pay productivity dividends elsewhere throughout the wider health system. - Incentivising staff to help tackle waiting lists – Calderdale and Huddersfield NHS Foundation Trust's introduction of a bespoke payment model, alongside the trust's efforts to optimise the tracking of patients, has resulted in a significant reduction in the number of patients waiting over 52 weeks for care. The trust's theatre improvement model has also helped to engage staff and foster a culture of continuous improvement throughout the trust's theatre activity, benefitting both staff and patients.
This report shares some of the approaches trusts have taken to deliver increased productivity levels, despite a challenging operational context. Trusts will continue to explore all available avenues to eliminate waste, drive up activity levels, deliver high-quality care and provide greater value for money to the taxpayer.