Trusts are making great strides in recovering services, including carrying out more diagnostic tests than ever before and bringing down the number of people experiencing the longest waits. Figures show the efforts of frontline staff to treat high numbers of patients and to tackle long waiting lists. The number of patients waiting more than 78 weeks has decreased by 79% since December 2022 (NHSE, 2023a).

However, a challenging picture remains across all services. In mental health, recently published data shows continued high demand and referrals up by 15% in March 2023 from the month before, an increase of nearly 60% from before the pandemic (NHS Digital, 2023a). May was the busiest on record for emergency care, with over 2.2 million A&E attendances, representing the third highest total since records began.

Intense pressure on an overstretched workforce exacerbates the operational and financial pressures trusts are dealing with. The NHS continues to have persistently high levels of staff vacancies – currently sitting at 112,000 with a recent marked increase in the number of more qualified staff leaving the service or retiring early (GMC, 2022). While NHS staff numbers have increased, they have not kept pace with the scale of demand the service is facing or demographic changes. And while the NHS Staff Council has accepted a revised pay offer for staff on Agenda for Change, this was not accepted by all the relevant unions, and there remains uncertainty about the impact of industrial action by junior doctors and consultants. The challenges of an underfunded and overstretched social care system also continue to have serious consequences.

It is in this context that the NHS is tasked with recovering performance to pre-pandemic levels which will require major improvements in productivity. The Chancellor has recently announced the Chief Secretary to the Treasury will undertake "the most ambitious public sector productivity review ever undertaken by a government" (Parker and Fisher, 2023). So what might this mean for the NHS?

Despite performance gains to date, the NHS is tasked with delivering yet more activity within existing resources as well as taking further costs out of the system without impacting on patient care. This will present a major challenge for providers and staff, already stretched to the limit.

In this report we explore the main barriers trusts are facing as they seek to recover performance and improve productivity. We also consider the financial impact of current pressures and the scale of the efficiency ask, which is even more stretching than in 2022/23.

We look at what trusts are already doing, both within their own organisations and in collaboration with system partners, to improve patient flow, reduce costs, deliver operational efficiencies, and improve productivity.

We also highlight what is needed from government and national bodies, in the short term and long term, to enable NHS providers to deliver the level and quality of healthcare the public expects and deserves.