The COVID-19 pandemic has had a lasting effect on the working practices in many industries and organisations, and the NHS is no exception. Video outpatient appointments have become increasingly common for many hospital specialties and over one in three GP consultations are now conducted virtually, compared with one in seven before the pandemic [1,2]. But perhaps the greatest effect has been on non-clinical and previously office-based roles, where working from home – or ‘WFH’ – has gone from the exception to the norm. In deciding where to draw the line, the question for NHS leaders is: is it really working?

Before the pandemic, such roles were routinely based in the office, with the possibility to work the odd day or two from home per week by special request. Now, many NHS organisations – ICBs, Trusts, as well as the centralised bodies – adopt a predominantly home-based ‘hybrid’ model, with an expectation that a worker’s own home is the main base, and the office is used only for certain activities, such as inducting new starters and training [3]. It is now typical for day-to-day work, meetings, and even interviews to take place entirely online through platforms such as Microsoft Teams and Zoom.

While these technologies doubtlessly represent a marked improvement from the digital offers pre COVID-19, they are nonetheless limited in their ability to replicate the office working environment. The NHS is complex, and so too are its problems. Current and longstanding issues – ambulance handover delays, A+E overcrowding, trolley waits, discharge delays, and social care capacity – are all intertwined in a sophisticated web of dynamics and dependence [4]. Can we really hope to untangle such deeply complicated issues while working from home? You need a flipchart, a whiteboard, you need animated discussion and debate, with contributions building upon one another organically and constructively. What is needed is proper teamwork. Not the stifling order of a virtual meeting where punctuated conversation flutters from one disjoint point to the next according to who raised their virtual ‘hand’ first. And leaders should also question – unashamedly – how much work really takes place from home, given “blurred lines between career and personal life” and undeniable opportunities for the less-than-scrupulous to exploit the inevitably reduced oversight [5].

Unfortunately, it is difficult to objectively measure the possible impacts on performance and productivity. This is a fundamental charge often levelled at public bodies, apparently lacking of the free-market mechanisms to clearly identify output and value. Arguably this extends to the individual employee level, where insufficient routine evaluation prohibits the kind of performance-related benefits that drive productivity in the private sector [6]. The recent Messenger Review on NHS leadership finds “a lack of consistency with appraisals – and in some areas, these were absent altogether” [7]. Without such assessments, reliably measuring performance is just not possible, and so any review on the impact of home-working can be only subjective at best.

Yet subjectivity is vulnerable to bias. Surveys show that people actually quite like working from home – they like the flexibility, the leisure opportunities, and the greater time with family [8]. And this is supported by the markedly slow return to the office in this country compared to others. So, putting aside those unswayed by personal preference, what incentives exist to draw oneself closer to something unliked by considering and promoting its benefits? It’d be like turkeys voting for Christmas.

Leaders should also consider their role in this – in embracing the personal preferences of staff within an increasingly visible attention on employee ‘wellbeing’. Like other parts of the civil service, the NHS has noticeably strengthened its wellbeing message in recent years [9]. While staff satisfaction and productivity are undeniably linked, there is surely a limit on how far this association can be taken. The worry is that employee-wants are put ahead of business-needs, and the taxpaying public are left to wonder whether the raison d’etre of their NHS is really to provide them with the best possible healthcare, or to provide the happiest possible place for its workforce.

And how does this all stack with another of the NHS’s increasingly visible priorities – of addressing inequalities. While the predominantly middle-class (former) office-workers can now avoid commute and childcare costs through routine home-based working, there is no such option for the relatively poorer nurses, porters and cleaners who have no choice but to travel in each day come rain or shine (and have little insulation from the currently exorbitant fuel prices). Should we also expect them to fit, as they do, their personal lives around work commitments, while better-paid home-working colleagues are able to do much the opposite. And what of the wider impacts on local economies, and the Resolution Foundation’s recent finding that “those areas that are expected to do relatively well out of working from home tend to [already] be relatively advantaged” [10].

This is not to reject home-working out of hand. Not least as it will be required in some form in order to compete in a labour market saturated by employers offering it as standard. For the NHS, avoiding such disincentives will be particularly important given the pressing concern over the adequacy of its future workforce, as recently highlighted by the House of Commons Health and Social Care Committee [11]. And while the findings of hitherto published academic studies are not exactly unanimous (likely indicative of insufficient time for proper examination), there is some evidence to suggest that in general “moderate levels” of home-working could actually increase productivity [12]. And, of course, there is the lower estates cost to factor in.

In summary, much has been made of the positives of working from home, but little attention has been given to its negatives. Yet, as we continue to emerge from the pandemic, there is still an opportunity for NHS leadership to shape future long-term working practices to ensure the best possible service can be provided to patients. To do so will require robust empirical evaluation of performance and productivity, combined with an acknowledgement that workforce happiness and wellbeing are important only as far as they allow the organisation to meet its fundamental aims and purpose.

References

1. Tyler, J. M., Pratt, A. C., Wooster, J., Vasilakis, C., & Wood, R. M. (2021). The impact of increased outpatient telehealth during COVID‐19: Retrospective analysis of patient survey and routine activity data from a major healthcare system in England. The International journal of health planning and management, 36(4), 1338-1345. https://doi.org/10.1002/hpm.3185.
2. The Health Foundation (2022). Understanding activity in general practice: what can the data tell us? https://www.health.org.uk/news-and-comment/charts-and-infographics/understanding-activity-in-general-practice-what-can-the-data-tell-us.
3. NHS England (2022). We work flexibly. https://www.england.nhs.uk/looking-after-our-people/the-programme-and-resources/we-work-flexibly/.
4. Royal College of Emergency Medicine (2022). Transparency about the scale of UEC crisis ahead of winter is vital for any strategy, RCEM warns. https://rcem.ac.uk/transparency-about-the-scale-of-uec-crisis-ahead-of-winter-is-vital-for-any-strategy-rcem-warns/.
5. Toniolo-Barrios, M., & Pitt, L. (2021). Mindfulness and the challenges of working from home in times of crisis. Business horizons, 64(2), 189-197. https://doi.org/10.1016/j.bushor.2020.09.004.
6. Lazear, E. P. (2000). Performance pay and productivity. American Economic Review, 90(5), 1346-1361. https://doi.org/10.1257/aer.90.5.1346.
7. Department of Health and Social Care (2022). Health and social care review: leadership for a collaborative and inclusive future. https://www.gov.uk/government/publications/health-and-social-care-review-leadership-for-a-collaborative-and-inclusive-future.
8. Kohont, A., & Ignjatović, M. (2022). Organizational Support of Working from Home: Aftermath of COVID-19 from the Perspective of Workers and Leaders. Sustainability, 14(9), 5107. https://doi.org/10.3390/su14095107.
9. NHS England (2022). Health and wellbeing programmes. https://www.england.nhs.uk/supporting-our-nhs-people/health-and-wellbeing-programmes/.
10. The Resolution Foundation (2022). Right Where You Left Me? Analysis of the Covid-19 pandemic’s impact on local economies in the UK. https://economy2030.resolutionfoundation.org/reports/right-where-you-left-me/.
11. House of Commons Health and Social Care Committee (2022). Workforce: recruitment, training and retention in health and social care. https://publications.parliament.uk/pa/cm5803/cmselect/cmhealth/115/report.html.
12. Vaitilingam, R. (2022). The impact of working from home on productivity, happiness, and careers: Views of leading economists. https://voxeu.org/article/working-home-igm-forum-survey.

Dr Richard Wood

Dr Richard Wood is an applied mathematician and senior analyst working in England’s National Health Service. As Head of Modelling and Analytics within a large Integrated Care System in the South West, his role involves designing novel quantitative approaches to help address the various operational and strategic problems facing the NHS. He has authored 30 academic papers and is a Senior Visiting Research Fellow at a local university. Before working in healthcare, he has enjoyed careers in bioterrorism analysis, financial risk, and capital modelling.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.