Pivotal not peripheral: the role of administration in the NHS

Before the pandemic hit, The King’s Fund, Healthwatch England, and National Voices embarked on a project to better understand how administrative practices in the NHS impact on people’s experiences of care and their outcomes. 

Anecdotally, we all have a story to tell of a referral letter lost, a phone call that went unanswered, or a labyrinthine experience trying to get to the right service. But what can the evidence tell us about the effect of administration on patients?  

The King’s Fund conducted some preliminary analysis—drawing on patient feedback—which highlighted that negative administration experiences can make a real difference to how people feel about accessing health services. Among people reporting poor experiences, variation when interacting with administrative aspects of NHS care—telephones, prescription requests, and engaging with reception and support staff—came out as a common theme. Yet, despite the wealth of anecdotal evidence about people’s experience of NHS administration, only limited systematic research had focused on patients’ experiences of admin and its impact. 

We decided to collaborate on surfacing people’s experiences and crucially what impact admin can have on people, particularly those with more complex needs. We used a range of methods, including in-depth interviews with service users and a workshop with British Sign Language users. 

Speaking to people illuminated that patient-facing administration is multi-faceted, and that people encounter different aspects of administration across a range of healthcare settings. Their testimonies unearthed a wide range of issues which are material to providing high-quality healthcare and should be taken seriously. 

Some users spoke about how it is common to have consultations cancelled or postponed at short notice (sometimes having secured cover for caring commitments or taken time off work). For others, it was not hearing from services that was an issue—for example, after a diagnostic test they didn’t hear anything and therefore felt they needed to proactively ask about their results. 

People with experience of multiple health and care needs talked about particular challenges. For example, the accumulation of communications from services can be difficult to decipher, sometimes contradictory and burdensome to keep track of. For people with particular communication needs—such as people for whom British Sign Language is their first language—default communication channels can be experienced as a barrier to accessing timely and appropriate care. 

We heard of serious impacts which go far beyond mere “inconvenience”, but have a pivotal effect on people’s healthcare experiences and can impact their health and wellbeing. These issues come with heavy financial and emotional cost, make it more likely people will self-medicate instead of seeking help, and undermine public confidence in services. Troublingly, the stories we heard from service users suggests that administrative deficiencies may be contributing to health inequalities. Users have to be resilient and sure of their entitlements to compensate for some of the administrative weaknesses they encounter—as well as having the resources, time, and knowledge to navigate clunky systems.  

We did not do this work to criticise people who work in administrative roles in the NHS. On the contrary. For too long “admin” has been overlooked or inaccurately elided with “red tape.” This couldn’t be further from the truth. Effective administrative processes and communication—and creating and running reliable and accessible systems as well as supporting and training staff—is a crucial element of providing good quality care. 

To truly help people—and address the gaps between those who achieve good access, experiences, and outcomes and those with more multi-faceted needs—more attention needs to be paid to the role and contribution of administration. 

A new approach wouldn’t only help patients. Every day NHS staff are expending time and effort supporting service users to navigate deficient administrative processes. Indeed, some participants in our research went out of their way to acknowledge the lengths staff go to in solving administrative errors or deciphering confusing processes. In the wake of covid-19 and at a time of growing need for healthcare, concerted efforts to address these commonplace frictions could go some way to improving working environments for staff.      

With vaccine roll out forging ahead and the government planning legislative change to support integration, thoughts are rightly turning to building back better and developing truly coordinated models of health and care. These aspirations are welcome—if dauntingly ambitious. Robust, user-friendly administrative processes will be central to delivering tangible change for patients (and staff). It’s time to talk about admin.

See work published 24th June 2021:

National Voices’ Paper Works: the critical role of administration in quality care

The King’s Fund’s Admin matters: the impact of NHS administration on patient care  

Healthwatch England: Focus on NHS admin is needed to improve people’s experiences of care.  

Savannah Fishel, Policy and Engagement Officer, National Voices @sav_fishel 

Leo Ewbank, Researcher, The King’s Fund 

Imelda Redmond, National Director, Healthwatch England @Redmond_Imelda

Competing interests: none declared