NHS productivity lags as recruitment fails to keep pace with demand

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

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

This difficult context is casting a shadow over the government’s goal that hospital waiting lists should be falling by the next election. Health consistently ranks as one of Britons’ top concerns, exceeded only by the state of the economy.

The health service’s problems are often blamed on a lack of workforce planning, which has led to a severe shortage of homegrown nurses and doctors. Close to 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, a data analysis by the Financial Times suggests that more staff alone will not change its trajectory.

Building on research carried out by the Institute for Fiscal Studies think-tank last year, the FT found that the NHS in England has 11 per cent more nurses, 10 per cent more consultants and 16 per cent more junior doctors than pre-pandemic — even after adjusting for higher rates of staff sickness absences. The number of nurses increased by just 3 per cent between 2010 and 2019.

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

The number of incidents recorded by ambulance services was 5 per cent lower in April 2023 compared to April 2019, despite 35 per cent more 999 calls.

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

However it was “not obvious” that the number of frontline staff was “the binding constraint”, he said. 

He added that if the debate focused on staff numbers, with politicians promising specific rises in nurses or doctors, “we might neglect things like investment in the [NHS] estate or in management systems or in just making the NHS a better employer”.

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

In 2020-21, at the height of the Covid crisis, healthcare productivity fell by about 25 per cent in England, the most recent Office for National Statistics data suggests. The period included a big spending infusion to fund coronavirus testing and vaccination programmes.

Charles Tallack, head of data analytics for the Health Foundation, a research organisation, cautioned that headline productivity measures did not necessarily capture all activity that made patients’ lives better.

He pointed to “really effective preventive interventions that stop people going into hospital”, yet “show up as less output in hospitals”.

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

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

This has meant a 17 per cent fall in the value of capital per worker since 2010-11. Tallack cited ambulance paramedics who were forced to remain outside hospitals with their patients for hours, for lack of an available bed.

“That’s not really anything to do with how hard the paramedics are working” but “a consequence of things being blocked in hospitals”, he added.

Icaro Rebolledo, lead economist with the Health Foundation’s Real Centre, suggested the changing composition of the workforce was a significant factor. Since 2018, junior doctors had increased more than any other category.

“So you have a mix of staff that now is more skewed towards junior members of staff, who can therefore do less,” he said. There had been considerably more “churn” in NHS ranks in the past few years, he added.

Matthew Taylor, chief executive of the NHS Confederation, who speaks for managers on the frontline, emphasised the need for staff to be better resourced.

“A large company that was keen to boost its productivity would be wanting to invest in technology, and capital more generally,” he said, pointing to the NHS’s £10.2bn repair and maintenance backlog. The UK significantly lagged other comparable countries in its level of capital spending, he noted.

“It is just common sense that an organisation that is starved of capital investment is going to find it hard to achieve the productivity gains.”

Staff reported that patients seemed to be in worse health than they had been before the pandemic. “We don’t know enough about this, but there just seems to be more and more complex sickness in the community,” Taylor added. 

The key question for ministers as much as NHS leaders is whether the health service can manage to bring down long queues for care before the general election expected 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 the NHS has been able to carry out, “treatment volumes and the waiting lists are heading in the right direction”. 

Hospitals were becoming more adept at providing emergency care and routine operations on different sites to guard against cancellation of non-urgent care, and adapting rosters to cope with the effect of higher staff sickness levels.

But about 8mn fewer episodes of treatment from the waiting list had been carried out during the first two years of the pandemic than would have been expected pre-Covid, he said, and it was unclear what the longer-term impact of this missed care would be.

While it was “within the realms of possibility” that the NHS would meet the government’s targets, “they were challenging when they were set [and] I’d say they’re 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 had reduced the number of patients waiting for more than 18 months by more than 90 per cent since the September 2021 peak and virtually eliminated two-year waits for treatment.

It added: “There are record numbers of NHS doctors, nurses, midwives and nursing associates registered to practice in the UK, and we will soon publish a long-term workforce plan focused on recruiting and retraining more staff.”

The NHS said: “While this analysis does not cover A&E, diagnostic or other hospital activity, the NHS is treating more patients than before the pandemic and despite industrial action and the busiest winter on record staff treated 400,000 more people in the first three months of this year than last.”