The UK National Health Service is under scrutiny for failures to increase productivity despite increases in funding¹. What are services in the UK to do to increase their productivity, with issues of growing older populations, increased technology costs in a time of financial challenge?

Perhaps a good place to start is to understand what productivity actually is and what it isn’t. Often productivity is thought to be efficiency, cost savings or reductions in investment; all of which are inaccurate.

Productivity describes what is produced for a certain set of inputs. The product of a motor vehicle factory are cars, busses, trucks etc. Money and physical resources go in and a product comes out. Your factory becomes more productive if it produces more cars for the same resources. On a national scale, we talk about Gross Domestic Product (GDP); the sum total of all production for a given economy. Greater output for static resources implies efficiencies but could also be as a result of innovation. The NHS has a long history of driving efficiency while ignoring innovation, for example the infamous and ongoing Cost Improvement Programme (CIP) which most often driven reductions in costs without due focus on outputs.²

A key question to ponder is: what is healthcare product? Here, there is much debate and not much consensus. The argument made here is that the product of healthcare is quality of life (QoL). If I have mobility issues then perhaps, I see a podiatrist, physiotherapist or have a knee replacement. Either way I don’t necessarily want a knee operation, a shoe insole or a set of exercises to do. What I want is to play with my grandchildren, ride my bike, get to work etc. I want that intervention so I can live my life without pain and hindrance.

If we accept this then we could say that the product of healthcare is the sum total of the quality of life gained by patients from the interventions offered.

It follows that we must measure how quality of life is improved or symptoms reduced. Let’s assume we can do that for the mobility issue described above. Let’s imagine we assess QoL as the person presents for help (T1); we intervene in whatever way; we assess QoL at a point (T2) after the intervention and most likely at discharge.

So, the total gain for these five patients is 19 points. We won’t get caught up in what 19 points means, but we could agree that 19 points is better than 10 points. If 19 points is the total product of this process the question arises: how to increase the productivity? Well in two ways; either we improve the quality of our clinical care thus driving up T2 scores or we see more patients (Patient6 or more). This leaves us with the following conclusion:

We improve productivity in healthcare by (1) improving quality or (2) increasing the volume of patients treated without quality falling.  

A number of issues fall out from this.

What we measure really matters, and there are challenges unique to different areas of healthcare (see Tracy & Hilton on Mental Healthcare as an example³). If you just measure the number of operations done, for example, you may focus on volume but nothing on quality. If you measure proxy measures (such as how often patients meet clinicians) there is no guarantee you will impact on productivity as you won’t know whether either quality or volumes are increasing. You might inadvertently incentivise anti-productivity behaviour such as extra appointments that have no value. If a particular physiotherapy intervention is effective yet brief, but if leaders insist on more contacts, you might find clinicians doing more sessions that are not needed just to increase contacts. Contacts go up, but productivity is really static or falling if volume falls as a result.

Practical Considerations

Measuring what is done doesn’t mean that productivity is increased, but it might be a great first step.

Leaders must be careful what they measure. Staff may well respond but will these changes actually increase quality or volume?

Clinicians rarely get excited about the prospect of seeing more patients, but they do love delivering higher quality treatment. This, in turn, might be a great place to start a meaningful conversation about productivity.

References

1. Freedman, S., & Wolf, R. (2023). The NHS productivity puzzle. Institute for Government. Jun, 2023-06.
2. Appleby, J., Galea, A., & Murray, R. (2014). The NHS productivity challenge. Experience from the front line. London: The King’s Fund.
3. Tracy, D. K., & Hilton, C. (2024). Productivity in mental health services. Why does it matter and what do we measure?. BMJ leader, 0, 1-6.

Author

Dr. Ryan Kemp – Director of Therapies, Central & North West London NHS Foundation Trust; Chair, Division of Clinical Psychology England in British Psychological Society; Honorary professor of Clinical Practice, Brunel University of London.

Dr. Kemp is a clinical psychologist, former clinical director with particular interests in compassionate leadership, innovation and quality improvement.

Declaration of interests:

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