Join the dots....

Well there it is folks. The NHS Long Term Workforce Plan has been launched to a fanfare almost as loud as a Number 10 Christmas party.

I’m actually a supporter of the concept behind the plan - it’s needed. The current system of restricting the supply of clinicians based on a series of vested interests and frankly paternalistic approaches to planning needed to be smashed to pieces.

I’m not however a fan of the headline grabbing nonsense that this plan will solve all problems over the next ten years if we simply stick to it. This is the oldest political trick in the book - kicking the can down the road.

We have an urgent and immediate need to improve services today. Patients are dying on trolleys, ambulances unable to get to patients in time, waiting lists out of control and cancer care a national shame.

Anyone who watches the NHS will know these last few weeks have been busy and a lot of headlines have been generated. We’ve had:

• A Kings Fund Report showing the NHS has comparatively worse outcomes than its peer systems in other countries.

• A report from the Institute of Fiscal Studies (IFS) which claimed a “chronic” shortage of managers was to blame for poor NHS productivity.

• An NHS Assembly report criticising the “fixation on acute care” and again pointing to a lack of management resource.

It’s easy to read these reports in isolation but I am concerned that policy makers already do too much of that. There just isn’t any joined-up thinking anymore. If there’s one thing the NHS is definitely not short of, it’s the plethora of initiatives aiming to tackle one part of the system in isolation from the rest.

The excellent Health Policy Insight pointed out years ago that healthcare is an ecosystem - if one area isn’t in balance it will have a direct impact on the rest. Policy makers appear to have had a “Men in Black moment” as if they’ve had that gizmo that wipes your memory applied to them.

The ability to focus on things that we actually know work, because it’s been proven in the past has been lost and replaced with the Silicon Valley method of “break things fast” by trying unproven and expensive solutions e.g., FDP.

Despite the various expert and think thank reports there is one fact that is undeniable: deteriorating performance by almost any measure you look at. GP access, ED waiting times, waiting lists, cancer care, social care, mental health are all in crisis and I could go on.

The NHS is too complex to fix in one article of course, but I would like to break the cycle of focussing on one story and join the dots about what all these reports are telling us generally, as well as focussing a little deeper on the area I know the most about patient flow.

Common Findings

Before the recent headlines, a very thorough report was produced by the National Audit Office in November 2022, looking specifically at waiting list backlogs. Amongst its excellent findings it pointed to a serious problem with NHS productivity which could not be explained by sickness rates alone. Two issues came to light:

1. The loss of goodwill, with staff no longer willing to work paid or unpaid overtime.

2. Reduced management focus on cost control and operational rigour.

More recently, the Kings Fund report comparing the NHS to other countries found that administrative spend in the NHS was “lower than average”. To put that into perspective, France spends 5.5% of its health budget on administration and the UK just 1.9%. Some of the right-wing headbangers pointed to this as a good thing because “everyone hates managers” but just pause for a second and ask yourself why it’s so hard to get that appointment for your mum? Yep, a huge part of it relates to administration.

You know things really must be bad when doctors themselves are calling for more management as was the case in the NHS Assembly Report , where the indomitable Dame Clare Gerada gave us my favourite quote of 2023 so far:

Quite.

Whilst these reports contain other findings which we will cover later, one specifically was entirely about this issue: The NHS Productivity Puzzle by the IFS pointed out a decline in productivity “despite rising spend and higher levels of clinical staff”. This report went further than the rest in calling out politicians for their headline grabbing messages about reducing management despite “…the notion that reducing managerial staff would somehow ‘free up’ front-line operations is not supported by literature. Hospital-specific studies have found a strong association between ‘good management practices’ and better clinical and financial outcomes.”

Other Important Findings

Almost all reports pointed to the NHS being a “treatment rather than prevention service”. This means that too often resource is sucked into acute care with not enough directed at the causes of ill health in the first place. A universally acknowledged good place to start would be a National Obesity Plan whereby taxation and regulation are used to supplement healthcare policy.

Another big, if not unsurprising finding was that the NHS has comparatively lower bed capacity and is operating at “unsafe levels”.

Lastly, in terms of productivity Outpatients is singled out as having the biggest issue whereby activity has dropped relative to staffing. Whilst various reports conjecture as to the reason for this, I have my own theory.

Let’s talk Elective Care

With the nationally reported waiting list continuing to rise, NHSE policy has fallen into the trap of chasing the longest waiters. Those of us who understand waiting lists know that continually chasing the end of a waiting list means you are literally chasing your arse forever.

To address a growing waiting list both ends of the list need to be tackled simultaneously. Whilst there have been some initiatives (NHSE recently launched a first outpatient programmes), progress has actually gone backwards. Why?

Undoubtedly, as some have mentioned, a shortage of diagnostic capacity is a factor. However I would argue it isn’t the biggest factor.

To be clear, 2/3rds of the reported waiting list is now non-admitted. The productivity challenge mainly rests in outpatients. And the reason no-one talks about is: EPR systems.

Clinicians hate doing outpatient clinics. Every single one I know tells me this is because of the administrative burden. This can be linked back to previous points about under-resourced administration however, more subtly, the rollout of EPR systems is placing increasing responsibility for recording data on clinicians.

It would also be remiss of me to leave this issue with the reported waiting list only. A much bigger (and not talked about enough) issue is the non-reported waiting lists and the level of clinical risk that isn’t visible to anyone. Only last week we had the scandal of children going deaf because there was no visibility of them nationally. These lists are responsible for the increase in Primary Care workload and no one is having a serious debate about it.

Let’s talk Urgent Care

Whilst everyone points to bed capacity and this is definitely a problem, I believe a much greater problem is the drop in elective activity. The health system is an ecosystem. If elective activity drops to the extent it has, patients will overwhelm both ED departments and Primary Care. Join the dots - these things are all interconnected. ED departments are full of patients on elective waiting lists who end up needing emergency treatment.

GPs are increasingly managing the non-reported follow up waiting lists that are not being seen in secondary care. Quite quickly the entire system becomes clogged up and everything deteriorates at once.

Conclusions for Policy Makers

So what should policy makers be doing in the face of all this evidence? I have some suggestions:

• Increasing clinical (or as the government like to call them ‘front-line’) staffing levels will make no difference to productivity at all. If anything, evidence suggests it makes it worse.

• Tackling the loss of goodwill is about staff retention. Looking after and rewarding existing staff for the job they do is a priority if we want to improve productivity.

• Increased administration and management resource is urgently required. As the NAO put it “operational rigour” needs to be a priority.

• The “fixation on acute care” needs to be corrected. Infrastructure, estate and capital has to move away from acute care and into prevention and patient participation. Data transparency will play a huge role in this aspect.

• Bed capacity needs to be significantly increased - and not just in acute care, if anything, a more important expansion is required out of hospital so that patients can be safely discharged into the community.

• Outpatient transformation initiatives are not working. The NHS needs to seriously reconsider both how EPR systems are designed and whether it should be clinicians or administrators who record the data.

The NHS Workforce Plan addresses none of these issues. Where are the policies that will?