The NHS productivity puzzle: Why has hospital activity not increased in line with funding and staffing?, 2023, Freedman & Wolf

[CRG]

Institute for Government

"This report – written jointly report by the Institute for Government and Public First, and funded by the Health Foundation – assesses why NHS hospitals are failing to deliver higher activity despite higher spending on the service and higher levels of staffing over the last couple of years.

It argues that politicians need to urgently focus on capital investment, staff retention and boosting management capacity, and sets out key questions for policy makers to address if they want to solve the NHS crisis. The NHS has been on a longer-term negative trajectory: most of the challenges identified in the report existed before the pandemic and have been exacerbated since.

The report particularly identifies the following as causes:

• Hospitals are chronically undermanaged, and where existing managers are operating they have too many constraints and poor incentives.
• Underinvestment in capital – including a lack of hospital beds and many beds filled by people who should not be in them.
• An exodus of senior staff – with inexperienced replacements recruited.

The report also draws on interviews and roundtables with dozens of experts and clinicians. It is published after a terrible period for the NHS: the elective waiting list stands at over 7.4 million and continues to rise, ambulances took 90 minutes to respond to strokes in December, and 10% of people attending A&Es waited more than 12 hours in February.

With NHS satisfaction levels at record lows and with an election next year, the report says politicians need to engage with key questions about how the crisis in hospitals can be addressed."

PDF: https://www.instituteforgovernment.org.uk/sites/default/files/2023-06/nhs-productivity-puzzle.pdf

Twitter thread:

 

[Jonathan Edwards]

Looks like waffle to me.

It needs to be funded.

 

[FMMM1]

The NHS has been on a longer-term negative trajectory:

Yea funding levels are much lower than e.g. Germany & France --- vague though of something like --- second law of thermodynamics(?) --- energy cannot be created or destroyed --- anyway --- you can't have a health service like Germany or France without funding at comparable levels.

 

[Arnie Pye]

"This report – written jointly by the Institute for Government and Public First, and funded by the Health Foundation – assesses why NHS hospitals are failing to deliver higher activity despite higher spending on the service and higher levels of staffing over the last couple of years.

I would be interested in knowing what is covered by the funding numbers and the staffing numbers quoted. For example, if the funding spent on the NHS is also covering the cost of money spent on private companies apparently working on behalf of the NHS then I'd like to see graphs and numbers actually given to the NHS for its own purposes, not combined numbers for the NHS and the private sector.. The same is true of the staffing numbers. If the numbers cover the private sector working on behalf of the NHS and also the numbers working for the NHS itself, then I'd like to see those graphs too.

 

[Hubris]

If productivity doesn't increase with more funding and staff it means the incentive structure is broken.

 

[Peter T]

I am not sure I can comment without breaching at least two forum rules. (Is this then also a breach of forum rules?)

 

[Trish]

I am not sure I can comment without breaching at least two forum rules. (Is this then also a breach of forum rules?)

No!

 

[FMMM1]

If productivity doesn't increase with more funding and staff it means the incentive structure is broken.

Yes -

It could mean all sorts of things ---data @Arnie Pye suggested might give clues.

My neighbors a casualty doctor in an NHS hospital - he's employed via some employment agency or similar "vehicle" -- has been for decades.
His mate [doctor] gave up a full time NHS job [5 days] and went part time [3 days] --- no significant loss in pay --- via some employment agency or similar "vehicle"

So there are lots of ways to spend more money without improving efficiency/productivity --- 5 days (£)=3 days (£)

I think Jonathan Edwards point is still the main factor -- funding --- if you want a health service comparable to Germany or France

 

[Shadrach Loom]

Useful blog post here by one of the authors, which succinctly reinforces the important points about exactly where any additional funding should best be directed.

https://samf.substack.com/p/how-bad-does-it-need-to-get

 

[Jonathan Edwards]

Useful blog post here by one of the authors, which succinctly reinforces the important points about exactly where any additional funding should best be directed.

I am singularly unimpressed by that. The solution suggested is more managers. And yet the author complains about too many managers hanging managers.

The author is clearly a manager. What they may not realise is that the NHS worked rather well in the 1970s-80s with virtually no managers at all. You do not need managers if the people actually doing the work know what they should be doing and have resources to do it. We just got on with it.

Almost all the managers are there to move money about or decide how money should be allocated. If there was no 'internal market' none of this would be necessary. And if there was no penny pinching even more so, since the managers are mostly there to penny pinch.

The real change we need is to stop GPs from functioning as a means to stop or delay people seeing staff who actually know what to do and let people go straight to someone who does. You then would have cancer survival figures reasonably comparable to Europe instead of significantly worse.

 

[rvallee]

Can't really judge about the NHS, but it seems pretty much identical everywhere. Healthcare expenses have risen higher than all other categories (and the rise itself is still faster than everything else), it's not commoditizing at all, where costs should go down over time because of efficiency and progress. And it's delivering less and less for it.

Our healthcare systems (plural, each province does its own local things) are also in crisis in Canada. In fact, have been for decades. Our entire model of healthcare is built around GPs managing everything. 1/4 Canadians don't have a GP and it's been at this rate for at least half a century, and was even worse before. I have a GP, and yet no health care because the system discriminates against my disease, and none of this is even accounted for. There is no plan B for that, it's a lottery system with many draws between someone's needs and a working solution.

Frankly, I think that much of this is simply because there is more information, it's harder to bury this data than it used to be. It's not as if healthcare was ever great anywhere, it's always barely hanging by a thread and growth in life expectancy was simply never met with corresponding ability to deal with more morbidity. In a sense, the success of acute medicine is ruining the rest of healthcare, keeping sicker people alive for longer sounds good until you realize that you actually have to do something about so many sick people. Problems that used to "go away" on their own don't anymore, our societies always relied on pumping out as many children as possible so that those who survive would take up the slack, and we haven't adapted to that. Social media is also shining a light on the dark areas of medicine, discrimination and failure that used to go unnoticed and unrecorded. The profession is criticized from all sides, and rightfully so, but no one seems to know how to unblock this mess.

I'm not really sure there is a solution out of this that isn't all about AI medicine. In the end it's the shortage of resources that breaks everything. There probably could be 10x as many MDs and there would still be unmet needs. The solution to this growing failure is a paradigm shift away from the old model, it's reached its limit years ago.

No one had solutions for food shortages, famines and generally lack of sustenance before science and technology made the problem mostly go away, although relying on so many chemicals has probably caused plenty of problems of their own. In the end all progress is technology, anything else is mostly for show.

 

[Shadrach Loom]

I am singularly unimpressed by that. The solution suggested is more managers. And yet the author complains about too many managers hanging managers.

The author is clearly a manager. What they may not realise is that the NHS worked rather well in the 1970s-80s with virtually no managers at all. You do not need managers if the people actually doing the work know what they should be doing and have resources to do it. We just got on with it.

Almost all the managers are there to move money about or decide how money should be allocated. If there was no 'internal market' none of this would be necessary. And if there was no penny pinching even more so, since the managers are mostly there to penny pinch.

The real change we need is to stop GPs from functioning as a means to stop or delay people seeing staff who actually know what to do and let people go straight to someone who does. You then would have cancer survival figures reasonably comparable to Europe instead of significantly worse.

I’ve never has much time for the cult of the front line. In any walk of life, practitioners are hopeless at running operations at scale.

You hark back to the good old days of “just getting on with it” when clinical eminence and decision-making was unchallenged. But that’s precisely the culture that allowed the luminaries of psychological medicine to take on ME.

I’m not even sure that your practical suggestion would make any difference. My experience as a non-ME patient is that GPs are reasonably speedy at issuing referrals, which then disappear into the black holes of consultant-led, administratively inept, departments within acute trusts. Self-referral would not make much difference to that; more and better management within those trusts likely would.

Anyway, the main point which I’d hope that Westminster and Whitehall take from this report is the glaring need for capital (as opposed to revenue) NHS investment.

 

[Jonathan Edwards]

You hark back to the good old days of “just getting on with it” when clinical eminence and decision-making was unchallenged. But that’s precisely the culture that allowed the luminaries of psychological medicine to take on ME.

Actually, I disagree. The BPS took over when they saw a way to market penny pinching for fatigue - selling it government and insurance companies alike. And that really came in the nineties. That sort of pseudo commercial psychiatry did not exist in the 70s and 80s.

I’ve never has much time for the cult of the front line. In any walk of life, practitioners are hopeless at running operations at scale.

I would like to see some evidence for that in context. My father in law ran a very large radiology department as a clinician and physicians knew who was reporting and could get detailed advice. Now we have a system where reporting might as well be done by a robot.

My experience as a non-ME patient is that GPs are reasonably speedy at issuing referrals, which then disappear into the black holes of consultant-led, administratively inept, departments within acute trusts.

Well, 'speedy referrals' to nowhere are not much use are they?
In the 1970s if someone had a long term problem a hospital physician with expertise took on lifelong responsibility for them. I had patients I followed for twenty years. By 1990 that was discouraged as much as possible. All emphasis was in getting shot of people back to the GP.

I quite agree that the hospital system is broken - part of that is when it came to be called the 'acute sector' - but what I am suggesting is that there is no division between primary and secondary care - that no buck passing can occur because there is nowhere to pass the buck - it stops here.


The trouble with calling for management is that managers simply do not know what is needed. In the past doctors knew more of some resource was needed and asked for it. The system was not necessarily fair but as far as I am aware it worked as well as it reasonably could. When I developed rituximab for autoimmune disease around 2000 the treatment was licensed but the hospital managers said there were no rooms to give it. The nurses were shunted around the hospital and lots of patients could not get their treatments on schedule. I pointed out to management that when a hospital generates a world-beating innovation it might think it worth providing it in a safe and effective way. I got no reply so I resigned and became a philosopher and took an interest in ME research. Managers are to blame for the fact that twenty years on no further progress has been made in my line of work.

I do agree that shortage of money is really the whole problem though.

 

[Trish]

From my experience teaching in the further education sector (students aged 16-18 academic and vocational) some years ago, the funding model changed suddenly and instead of being funded via local authorities on the same basis as schools with a simple formula of numbers of full time equivalent students, we were switched to a far more complicated funding formula where every hour of class contact time for every student had to be tracked. The whole thing was incredibly unwieldy and required roomfuls of bean counters - where before each department had one secretary who did everything, including typing all our exam papers which we then had to do ourselves.
The management and administration staff got the upgraded computers and teaching staff had to share very limited supplies of their cast off computers and printers which kept breaking down.

The net result was teacher salaries falling behind school equivalents and work loads increasing, and a much higher proportion of the College's income going on management and admin. It didn't improve quality of education at all.

I suspect the same is happening in the health service.

 

[Sean]

we were switched to a far more complicated funding formula where every hour of class contact time for every student had to be tracked.

The demand to account for every minute of every day, and every paper clip and pencil, is so counter-productive. It is managerialism and accountability taken to the point of self-destructive insanity.

Apparently the concepts of diminishing return and workplace flexibility have really not been grasped by the managerial class.

 

[FMMM1]

I agree with Jonathan's comments re the rise in (flawed) psychology --- i.e. it was a convenient penny pinching ruse.
In Radio 4 Fit for Work a Minister states we can't let these people rot at home -- we have to improve the quality of their lives ---
So they removed their benefits and sent them to the "BPS/(flawed) psychology" road show --- cheap --- blamed them for not having the will to get out of bed --- (+) ticks in a lot of boxes for that policy! And yes the "BPS/(flawed) psychology" bunch were willing participants --- think some even patented "treatments" for sale to the NHS!