Improving productivity within existing models of care

1. Skill mix change

With almost 65% of the NHS operational budget spent on staff, improvements in how workers are deployed hold significant potential for increasing productivity. Traditional care models have resulted in the skills, knowledge and potential of various workforce groups being under-utilised. Many staff have not been supported to develop their skills and practice or work at the top of their skill set. Skill mix changes can boost productivity by developing staff to undertake tasks traditionally undertaken by higher band colleagues and organising teams such that all staff can work at the high end of their skill set more often.

This kind of role development is a strategy we’ve seen in a range of sectors, including law (paralegals), education (teaching assistants) and policing (police community support officers). For example, there is evidence that upskilling nurses and pharmacists in outpatient or primary care teams to play a greater role in managing conditions like diabetes or cardiovascular disease is cost effective and can improve key outcomes. Nevertheless, quality and safety must be at the heart of skill mix change, as there can be risks when transferring tasks to staff with less training; for example, simply replacing registered nurses with lower skilled staff can harm patient safety.

Skill mix change can also boost productivity by increasing the range of knowledge and skills in a team – for example through the creation of multi-disciplinary teams – improving performance and service delivery. Indeed, rather than simply transferring tasks between staff, effective skill mix changes focus on getting the most effective teamworking in place. Conversely, badly implemented skill mix changes can reduce productivity if they generate confusion about ways of working, create professional tensions or harm team dynamics. It’s therefore essential to involve staff in designing new working arrangements and to provide clarity about the scope of new roles.

Historically, much focus of skill mix change has been in secondary care, but now there is growing interest – including through the NHS Long Term Plan and People Plan – in opportunities within primary care. This includes making greater use of allied health professionals (AHPs) whose skills have historically been undervalued, such as paramedics, physiotherapists and pharmacists, in ways that would not only help meet demand but also potentially improve quality and widen the service offer available. Many challenges remain: overcoming professional boundaries; addressing regulatory rigidity (for example, extending the scope of practice for AHPs); reshaping pathways and ways of working; and supporting the development and regulation of lower paid bands, where there has hitherto been insufficient investment in training to fully capitalise on the potential for skill mix change.

Tackling workforce shortages is also clearly essential as the lack of staff in relevant roles also contributes to suboptimal task distribution and lower productivity. For example, our report Falling short highlighted a ‘hollowing out’ of the NHS workforce over the last decade, with the number of doctors and clinical support staff both increasing faster than the number of nurses. This created gaps in skill mix – with just 2.6 nurses per doctor in 2018/19 compared with 3.0 in 2010/11 – that have been associated with lower productivity: further Health Foundation analysis found that hospitals with more productive consultants are significantly more likely to have a higher proportion of nurses.

2. Patient activation

Health care isn’t a product but a service, where outcomes are necessarily co-produced with users. So patients are always involved in their own health care and the question is how they can be supported to contribute to their health as effectively as possible – especially for the many people living with long-term conditions who are only in contact with health professionals for a small fraction of their lives. Health care isn’t alone in this: recent decades have seen service industries strongly emphasise the role of users in co-creating value – as seen, for example, in how financial services have been transformed.

Patient activation describes the knowledge, skills and confidence a person has in managing their own health, though here we use it as a shorthand to refer to interventions that can increase activation, such as self-management support, health coaching and shared decision-making, including approaches that draw on community resources, such as peer support and social prescribing.

Greater patient activation can improve productivity by increasing the effectiveness of health care interventions, for example through increased medication compliance or better preparation for operations. On some occasions, there may also be some shift in activity from staff to patients, with staff capacity freed up (essentially a type of skill mix change). For example, shared haemodialysis helps patients become active partners in their care by training those who can to perform key haemodialysis tasks, which improves motivation, confidence and wellbeing, and frees up nurses to focus on patients who need more support. In this way, patient activation can also help optimise use of staff time by helping indicate where professional efforts are best directed.

Beyond improving the productivity of individual health care interventions, patient activation also has broader implications for resource use through its potential to achieve better health and reduce subsequent demand for care due to ill health. Research suggests patients with less knowledge, skills and confidence to manage their health tend to engage less with preventative health care and require more care episodes, generating higher costs.

While blanket generalisations are dangerous – in some contexts increased activation could lead to higher health care use – there is growing evidence of cost effectiveness in particular areas, such as self-management support for asthma and cardiovascular disease, and peer support for mental health and coronary heart disease. There is also evidence that shared decision-making leads to patients being less likely to choose intensive treatment options (such as surgery) and more likely to choose conservative – and generally less costly – approaches (such as physiotherapy).

Amid the pressures the NHS faces, it can be tempting to see these kinds of approaches as ‘nice to have’. But in many cases such approaches will be essential for reducing avoidable demand and maximising the value of care. 20 years ago, Derek Wanless’ review of NHS funding highlighted that key to sustainability was a world where patients are ‘fully engaged’ in their health, though we are still some way from that. While these approaches don’t necessarily require major funding, they do require a willingness to work differently and to value patients as active partners in their care. National bodies have an important role in supporting local systems to do this well – building, for example, on the NHS Comprehensive Model of Personalised Care and the National Academy for Social Prescribing.

3. Improving flow

Whereas skill mix change and patient activation both alter the inputs to health care activities, improving flow is about better movement of patients, resources and information along care pathways, with the potential to increase throughput. Poor flow can negatively affect patient outcomes as well as resource use by prolonging length of stay and increasing risk of errors.

A range of approaches exist for improving flow, of which perhaps the most well-known in health care is Lean (developed from the Toyota Production System in the mid-20^th century). Flow improvement techniques involve stripping out unnecessary actions, movement or waiting (‘waste’) from processes, and applying insights from queuing theory to improve throughput, such as reducing demand variation or better matching capacity to demand.

Opportunities for improving flow exist in many health care settings. One example is operating theatres, where 38% of theatre lists do not run to capacity due to late starts, slow turnarounds and early finishes. Recently a major focus for flow improvement has been emergency care (driven partly by the 4-hour target), with efforts to improve the ‘front door’ (eg early access to a senior decision maker), and ‘back door’ (eg timely access to discharge-related diagnostics). One of the most well-known examples of flow improvement in emergency care is Discharge to Assess (D2A), ‘discovered’ by a team at Sheffield in one of the Health Foundation’s improvement programmes. D2A involves discharging patients once they no longer need hospital care and assessing their ongoing care needs at home, rather than keeping them in hospital for assessment. Now D2A is being encouraged by NHS England, with the Health and Care Bill aiming to remove legal barriers, although recent planning guidance has confirmed that central funding to support D2A will stop after March 2022, raising concerns as to whether local health and care systems will be able to sustain the model. With the advent of Integrated Care Systems (ICSs), attention is increasingly turning to flow across whole pathways and systems – discussed in more detail below.

But while some flow problems and solutions are generalisable, many are specific to the contexts in which staff work, meaning teams on the ground need to be able to diagnose problems and design bespoke solutions. This means that only so much can be achieved through programmes to spread specific interventions like D2A. Instead, the emphasis must be on producing guidance to support providers (such as the SAFER patient flow bundle), and on building providers’ capability to identify and tackle issues (such as through the NHS–VMI partnership, which involves five hospital trusts working with the Virginia Mason Institute to develop Lean approaches). The insight that capability and methodology matter also lies at the heart of the Flow Coaching Academy (FCA), set up by the Sheffield team behind D2A. Rather than spreading specific interventions, the FCA trains people to lead flow improvement in their organisations, combined with guidance on methodology.

4. Technology-assisted working

Technology can boost productivity by improving processes in many different ways – supplying or analysing information, enabling communication, executing movements, and so on. Like skill mix change and patient activation, technology can rebalance the resources applied to an activity – such as when automation frees up staff to focus on areas where humans add more value. For example, a team at Imperial College Healthcare NHS Trust are using natural language processing to help analyse patient feedback surveys, thereby allowing the patient experience team to focus on improving services.

Alternatively, technology can improve flow by speeding up processes – through faster information processing, for example. It can also improve productivity by improving care quality – enabling greater analytical accuracy to enhance the effectiveness of diagnosis and treatment, for example. In many cases, technology can act as an enabler of the first three approaches described above.

While cutting-edge, medical applications of technology – such as robotic surgery or AI-driven scan analysis – often steal the headlines, there are also important productivity gains to be made through applying technologies to administrative tasks. This is especially true for high-volume, repetitive tasks like appointment scheduling, prescription management and payroll. This includes making better use of existing technologies. Robotic process automation, for example, uses software to allow transaction processing, data manipulation and communication across multiple IT systems; it has been deployed to improve administrative work in many industries, but not yet widely in the NHS, and is now a major focus of NHSX’s Digital Productivity Programme. Indeed, in some cases administrative and ‘back office’ work can be simpler to automate than clinical tasks, as there may not be immediate issues of clinical risk attached, and such changes may enjoy greater support if they free up staff for more rewarding work.

The key challenge for improving productivity is that technology produces benefits not in isolation, but only when embedded and used effectively, and this can require considerable effort to redesign roles, processes and ways of working.

Improving productivity by creating new models of care

The four approaches above can be used ‘incrementally’ to increase productivity within existing models of care. But they can also be used ‘transformationally’, to redesign pathways and create new models of care.

From a productivity perspective, pathway redesign is especially important because it creates the opportunity to consider value along the whole care pathway, rather than simply attempting to optimise productivity at isolated points. Crucially, rather than taking activity at any point in the pathway as given, considering productivity along a whole pathway opens up the possibility of reducing activity (and saving resources) at one point through changes at other points.

Historically, health services have evolved in ways that are too fragmented, reactive and hospital-centred for today’s health needs. These patterns of delivery can reduce effectiveness and create unnecessary costs, undermining the productivity of care pathways as a whole. Recent decades have seen considerable focus on specific types of redesign to address the fragmented, reactive and hospital-centred nature of services. These include:

• Integration: joining up, or coordinating between, services previously provided separately, to streamline delivery and potentially increase effectiveness. For example, skill mix changes can create multidisciplinary teams to deliver multiple components of care in the same setting (eg a multidisciplinary COPD clinic).
• Prevention: intervening earlier in a pathway to reduce avoidable demand later on. For example, creating enhanced support (eg community nurses) in care homes or providing self-management support (eg access to a health psychologist) to those with COPD.
• Enabling services closer to home: providing services in more convenient and less resource-intensive contexts to improve access and free up estate. For example, using smartphone apps and medical devices to manage patients at home (eg home monitoring of hypertension during pregnancy).
• Consolidation: concentrating services in specialist hubs to improve quality, increase throughput and generate economies of scale. For example, consolidation could involve the use of flow improvement approaches for high-volume elective procedures to reduce turnaround time and maximise theatre use (eg for cataract surgery).

The Five Year Forward View and the NHS Long Term Plan sought to encourage these kinds of new models of care. And some of the pathway changes seen during COVID-19 have accelerated these plans, especially greater use of digital consultations and increased delivery of care and support in people’s homes. Post-pandemic, there is greater focus on pathway changes that can support elective recovery and wider NHS recovery, such as community diagnostic hubs and surgical hubs, with the 2021/22 planning guidance calling for ‘whole pathway transformations’ in three high-volume specialties: ophthalmology, musculoskeletal and cardiac services.

It would be wrong to assume, however, that all transformative changes result from a single redesign process or represent the application of just one improvement approach. Alderwick and colleagues, for example, document how reductions in acute length of stay in recent decades have increased productivity, driven by improvements in drugs, technology and processes. For some surgical procedures, these kinds of improvements enabled wholesale shifts to treating patients as day cases, delivering significant productivity gains. For example, the authors estimated that for cataract operations the shift from inpatient cases to day case activity between 1998/99 and 2013/14 saved an average of around £40m per year by 2013/14 – equivalent to a productivity improvement of 14%. But these shifts were in several cases made possible by the gradual accumulation of benefits from multiple improvements over time, for example, new surgical techniques, advances in anaesthesia, better analgesics, improvements in discharge processes, and so on. So although significant gains can be realised at ‘tipping points’, such as shifting to day case surgery for a procedure, progress is often made through a series of steps rather than a single leap.

In addition to the general challenges of service change (such as double running services while innovations are tested), something that makes pathway redesign particularly difficult is that it usually involves working across organisational boundaries, both horizontally and vertically, where different teams and organisations face different costs and have different incentives. It is hoped ICSs will facilitate change by sharing costs and aligning incentives. But to be successful, legislative and structural changes will need to be accompanied by support to help ICSs redesign and implement new pathways in practice.

Second, policy will need to address that other component of agility: motivation. How can the uptake of productivity-improving practices and pathways be more effectively encouraged across the system?

• External incentives such as regulation and tariffs can play an important role in supporting adoption. The CQC’s recent moves to place greater emphasis on providers’ quality improvement work and on the adoption of innovation are positive steps. Tariffs and payments often don’t support the upfront costs associated with adopting innovations (backfilling staff time, providing training, etc), so reforming them to better support implementation costs will be important.
• External incentives don’t always make it down to the front line, however. Within a provider, much depends on culture and on the management and leadership of change: Are staff involved in shaping new proposals? Do they feel ownership of them? Are changes aligned with other strategic priorities and organisational values? Factors such as these will play a significant part in securing support for new ways of working.
• National leadership in signalling priorities is also crucial. A key lesson from service change during COVID-19 has been the importance of a shared mission at all levels of the system for galvanising action. The pandemic not only created pressure for service innovation, but also the common purpose that is key to translating pressure into results. The challenge for NHS leaders post-pandemic will be to recreate a sense of shared mission anew – as the best moments of health care reform in the past have managed to achieve – one that is about improving NHS care, not cutting costs. Equally important will be avoiding a ‘priority thicket’ of disparate initiatives which can stymie local leadership and make it harder to improve productivity.
• The dismantling of the NHS competition framework creates a moment to think again about the dynamics that drive service improvement. Over the last two decades, policies have placed heavy emphasis on external ‘levers’ (targets, competition, regulation, etc) but tended to underplay the contribution of the NHS workforce themselves, and the potential for change to come ‘from within’. An important thing about the improvement approaches highlighted above is that they are first and foremost quality improvement agendas, driven and owned by front-line teams; as such, they offer an opportunity to engage staff and to harness the intrinsic, vocational motivations of the workforce more effectively than an economically framed agenda.

These factors – improvement skills, infrastructure, management, culture, reflective capacity, shared mission, and so on – make possible the agility that enables successful organisations to seize opportunities and implement new ways of working rapidly and effectively. And they need attention in their own right. They don’t necessarily require vast amounts of funding, but they do require some – a tough ask when there are big financial pressures on the NHS. It’s always easier to justify investment when it’s linked to a particular solution. But while there are many ideas out there for improving NHS productivity, to really take advantage of them Government and NHS leaders must invest in creating a more agile provider sector independently of the specific improvements this will subsequently enable. Only by ensuring providers are in a position to take advantage of productivity-enhancing improvements across the board will the NHS be able to meet the demand pressures ahead.