• The NHS is facing a significant productivity challenge. The service must contain costs and use existing resources to increase activity, within a context of significant operational and financial pressure.
  • To improve productivity, trusts are improving patient flow and internal discharge procedures, delivering different delivery models for care (including virtual wards), focusing on staff wellbeing, harnessing provider collaboratives to inform joint working across pathways, and utilising analytics to inform clinical and operational decision making.

  • National data shows good early progress toward achieving the interim recovery targets for urgent and emergency care, while in elective services trusts have successfully reduced the number of long waits. However, substantial care backlogs still exist across mental health, community, and children and young people’s services. Despite sustained efforts by trusts, our survey shows that it will be very difficult for the NHS to deliver the government’s overall performance ask, protect quality of care, and deliver unprecedented efficiencies.

  • Trust leaders are significantly concerned about capacity to meet demand for services, and about staff morale and burnout. While there has been an increase in overall workforce numbers, this has not kept pace with growing and changing demand, and there is a shortage of key skill sets.

  • Prolonged industrial action poses a major operational constraint to recovering performance, and a significant financial risk to trusts, given the loss of elective activity income, and increasing costs due to agency spend and the impact of consultant rate cards.

  • Trusts continue to carry significant levels of risk across their estate. 73% of trusts surveyed strongly disagreed or disagreed that they have access to sufficient capital funding over 2023/24 to address capital maintenance backlogs.

  • Increased patient acuity, higher average lengths of stay, and the need for investment both in beds and in community and social care services are limiting the timely discharge of patients, and impeding trusts’ and systems’ ability to improve patient flow.

  • 89% of trust leaders responding to our survey said the scale of the efficiency ask this year is more challenging than last year. Trust leaders are concerned about the deliverability of the efficiency targets expected of systems and about what financial pressures may mean for the quality and scale of service provision in 2023/24.

  • While some productivity constraints are within trusts’ gift to address, there are wider barriers relating to workforce, bed and service capacity, patient acuity, social care capacity and industrial action that require support from government to address. In the short and medium term this will require:

    • expanding capacity in community settings

    • delivering the long-term workforce plan

    • resolving industrial action in negotiation with unions

    • enabling fully digitally connected estates

    • improving the coverage and quality of productivity data.

  • In the long term, the government must:

    • enable a step change in operational and strategic capital investment to enable material improvements in productivity growth

    • enable the NHS to invest in management capacity alongside the clinical workforce to help deliver operational efficiencies

    • provide a sustainable solution to social care capacity.


About our research

Our report is based on evidence from trusts across England and supplementary research. We took a mixed methods approach, conducting a survey and in-depth interviews. In April and May 2023 we carried out an online survey of chief executives and finance directors of all trusts and all trust types: acute, acute specialist, ambulance, community and mental health and learning disability. We received 110 responses to the survey. This accounts for over half of the provider sector, from all regions and sectors in England.

We supplemented the quantitative and qualitative findings of the survey with in-depth interviews and roundtables with finance directors covering a range of sectors and trust types, and additional desk research and analysis.