Calling a truce on the productivity problem
There is a productivity challenge facing the NHS, and we must collectively find a way to analyse the problem, agree on the root causes and set the conditions for improvement. All these steps are complex. In a blog I recently wrote for the Nuffield Trust, I laid out my central thesis that the reason we are not having the conversations we need about these issues is due to a lack of psychological safety in all layers of the system, from HM Treasury to the front line. While trust boards can put up an 'umbrella' of security over their own organisation, maybe even sometimes over a whole place or integrated care systems (ICS), this is increasingly hard in our febrile and tense national environment. Even where this is in place, it is challenging to do the vital analysis, research and local 'discovery' needed when the national system is mired in overt or covert narratives of blame.
This is urgent. All political parties are concerned to understand the central issues as presented – more money, more staff, lower outputs. The public are experiencing changes in terms of serious delays and problems of access – they know that something is different but even the language is misunderstood and contested. No patient has ever talked about outputs and no clinician goes to work thinking about productivity.
No study to date has got us very far in reaching a comprehensive shared understanding of this puzzle that all parties accept. There is ample evidence of a problem, but the questions about why we have this problem, and what can be done about it, are not sticking. That is the crucial bit of the puzzle. Why aren’t all parts of the system, from the Chancellor to the frontline, engaged collectively in pursuit of these questions? I would posit it is because the NHS is hearing this discourse that there’s more money, more staff yet lower productivity as a statement of accusation and dismissal of effort and worth.
I have previously called for a "productivity truce", where all parties acknowledge how they have become sucked into these subculture narratives of blame and easy tropes that have got in the way of the best research and understanding. If we could set all these aside, we would then be able to properly explore the key theories that explain what is happening, and crucially co-produce solutions. When I was a community trust CEO, I was in many rooms where we were arguing about measurement and, certainly, where I complained (rightly of course!) that community, primary care, mental health and indeed third sector activity were not counted or included appropriately. But despite the validity of that argument (and others), there is something going on.
We must look methodically at the theories that could explain the situation. Increasingly a statement about productivity lies at the heart of any announcements of new money into the health service – as shown with the Spring Budget – but there is significant uncertainty and often a lack of belief about how to deliver the assumed productivity improvements. Productivity and what "it" can achieve in the public sector is second only to AI as a magical idea that is going to be swiftly transformational.