It is accepted wisdom that the NHS is desperately short of staff. We regularly hear reports of the record number of vacancies and the need to use expensive agency cover. Yet the NHS in England employs the full time equivalent of 1.2 million people, nearly 200,000 more than they did in 2012. The increases in staff numbers are accelerating. The Institute for Fiscal studies has found there are 10.7% more nurses and 10.2% more hospital consultants than in 2019. The government is also on course to meet its target of having an extra 50,000 nurses in place by 2024.
None of this keeping up with demand. The King’s Find think tank found that the South East region has increased its full-time equivalent workforce by 17% from 2019, yet its vacancy rate grew by more than 12%. We seem trapped in a spiral where however many extra staff are recruited it will not be enough.
Undoubtedly there are specialities and services which are short of personnel and individuals who are under significant strain. Clearly an aging and growing population places more demands on the health service. Yet advances in medicine, such as keyhole surgery, mean that average length of stay after operations has reduced and many people can manage their conditions better with less intervention from staff. As Sir Jim Mackey, the government’s adviser on the NHS elective recovery programme, pointed out in a seminar hosted by the health service journal earlier this year, “The NHS has grown its workforce dramatically in the last two years but we are broadly doing 10% less work than before.”
It is surely worth asking the question what are all these extra people doing and why is it not making any difference? The recent NAO report on waiting times found that, “in 2021, the NHS was around 16% less productive than before the pandemic,” and that “on average, workers were not carrying out as many procedures as before.”
Instead of exploring why this is the case the NHS, unions and commentators insist that what is needed is a workforce plan based on recruiting an ever increasing numbers of staff. Yet what might be more helpful to patients is some real focused work on tackling the deep rooted inefficiencies in the NHS to enable it to make better use of the staff it has.
When I was on the Board of an NHS hospital, one of the managers lamented to me that he could schedule a maximum of four knee operations a day but in the private sector they manage eight a day. They were the same type of operations, in many cases the same surgeons, but the difference was that all those involved from the receptionist to the porter had an incentive to get through the list, to find those marginal gains that would make the process more efficient. Even within the NHS there are huge variations in how many procedures different hospitals carry out in a day.
It is clear that many opportunities to improve throughput are missed. Of the 7m people on NHS waiting lists, 80% will be seen in an outpatient clinic, but these clinics are notorious for being inefficient and making poor use of patient and clinician time. Improving administration like planning appointments properly, managing capacity, sorting out the logistics could carve out extra appointments and that would start to make a difference. Yet, as the NAO points out, trusts are already failing to meet the targets in the elective care recovery plan for increasing the number of outpatients.
Much of the problem is that NHS lacks many of critical elements of good organisational management. The fact that 12600 operations were cancelled last year due to administrative errors is just one indicator of this. Huge amounts of money has been wasted on commissioning management consultants to identify solutions but their reports are never implemented because the culture of the NHS resists and subverts any such changes in working practices.
As the government’s Messenger report into NHS leadership found “Collaborative behaviours, which are the bedrock of effective system outcomes, are not always encouraged or rewarded in a system which still relies heavily on siloed personal and organisational accountability.” Take away the corporate jargon that means the changes required to make the service run better, to use fewer people more effectively, that commercial organisations embraced years ago, are often impossible in the NHS.
Part of the problem is the way many doctors defend their own departments and are single minded in the defence of their own patients, but refuse to engage with any performance management, corporate activity or collaborate with their colleagues. They work miracles for their own patients but make running hospitals monumentally difficult.
The NHS, like all organisations where users have no choice defaults to accommodating the providers not the consumers. This lack of customer focus combined with the dead hand of the command and control of the NHS central bureaucracy means that inefficient use of staff, poor management and bad care is embedded in large parts of the service. That means, without radical reform, there will never be enough staff and never be enough money.
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