As we head into 2022, the health service faces unprecedented challenges with the ongoing pandemic and a mounting backlog of care – as well as the long-term challenge of an increasingly ageing and diverse population. Maximising productivity is critical if the NHS is to survive these challenges.

Given historic underfunding and an understaffed and exhausted workforce, this will undoubtedly be jarring for many to read

Given historic underfunding and an understaffed and exhausted workforce, this will undoubtedly be jarring for many to read. The biggest determinant of NHS fortunes will always be the funding it receives and over the last decade funding has not kept pace with demand – so it’s essential that the NHS receives the resources and staff it needs over the years ahead. But there is no escaping that, for any given spending level, every pound wasted contributes to unmet need or poorer services elsewhere. Even small changes in NHS productivity make a big difference financially: Health Foundation analysis of NHS finances estimates that every 1% reduction in productivity would require around an extra £1.5bn of funding per year in order to maintain quality and access to services.

So with pressures mounting on the NHS, what can quality improvement contribute to the productivity agenda? The answer is a lot.

Conflicting agendas?

Quality improvement and productivity are sometimes seen as conflicting agendas, with apparent tensions between improving care on the one hand, and saving resources on the other. For example, restraining pay and reducing the tariff for hospital services – both approaches on which the Government has relied over the previous decade – may produce short-term savings but could adversely affect quality if they undermine staffing and service delivery.

However, there is no necessary reason why improving quality and increasing productivity should be conflicting agendas. First, productivity is ultimately about improving the ratio of output per unit input, rather than reducing costs per se. And outputs can be defined broadly to encompass a variety of dimensions of quality – not just as the volume of treatments delivered but the outcomes and experiences they result in. Second, it is important to remember that efficiency is one of the Institute of Medicine’s six dimensions of quality, alongside factors such as effectiveness, safety, patient-centredness, and so on. Third, something we see in many of our Health Foundation funded improvement projects is that efficiencies and cost savings often come about as a by-product of attempts to improve other aspects of quality; in these cases, they are two sides of the same coin.

Improvement approaches and productivity

Productivity improvements can be made by reshaping and improving the delivery of care. But what approaches should the NHS be considering in order to increase productivity?

Technology can also be a powerful enabler of improved care and productivity

Improving flow – stripping out unnecessary actions, movements, or waiting from processes to improve patient experience and outcomes as well as efficiency – is perhaps the most well-known example of a quality improvement approach geared towards productivity. But there are many more. Interventions that increase patient ‘activation’, such as self-management support and health coaching, can also improve care and outcomes whilst freeing up staff capacity. Shared Haemodialysis, for example, helps patients to perform key haemodialysis tasks which improves their motivation, confidence and wellbeing, and frees up nurses to focus on patients who need more support. Work reorganisation to make better use of team skills is another example – such as giving nurses or pharmacists a greater role in managing diabetes in outpatient care or primary care. Technology can also be a powerful enabler of improved care and productivity: in another Health Foundation funded project, a smartphone app allows pregnant women at risk of developing pre-eclampsia to monitor their health at home and alert the hospital if they need to come in for further assessment, rather than using pre-scheduled appointments – enabling better use of clinical time.

Agility – the missing ingredient

Too often, health policy seems concerned with identifying opportunities and setting objectives for change, without taking account of providers’ ability to respond effectively

But while there are a range of promising improvement approaches for improving productivity, gains will depend on the agility of health care organisations to grasp these opportunities and implement them well. And here we see an implementation gap. For example, unless implemented successfully, skill mix changes can lead to unintended consequences that mean they may not be cost effective – such as when less experienced staff working in extended roles recall patients at a higher rate or take longer to complete tasks. Or in the area of technology, where benefits are also highly dependent on the effectiveness of implementation. For example, a US study reported that despite three hospitals adopting the same electronic record and order entry systems to improve quality and safety, outcomes varied; the first saw a significant rise in mortality, the second saw no significant change and the third a significant fall.

Too often, health policy seems concerned with identifying opportunities and setting objectives for change, without taking account of providers’ ability to respond effectively. To really take advantage of these kinds of improvement approaches, there must be investment in strengthening provider agility – building organisations’ improvement capability, investing in digital infrastructure, and providing effective implementation support in central programmes.

A shared mission for the NHS

Sustainable productivity gains are critical for the NHS and quality improvement will play a vital role in reshaping and improving the delivery of care. Crucially, service improvement approaches like skill mix change, patient activation, improving flow and greater use of technology can promote sustainable change in a way that also resonates with the broader motivations of the NHS workforce. Now is the time for policy-makers to invest in and support the workforce to build provider agility so that we can realise these benefits, faster.

Read more in the Health Foundation report: Agility: the missing ingredient for NHS productivity