The mythbuster: The hard choices the NHS avoids

There is something deeply embedded in how people think about the NHS that causes them to flee from hard choices and seek popular, simplistic solutions. There are also few commentators who seem to recognise that improvement often comes because difficult choices are faced rather than fudged. An effective NHS would make hard choices based on recognising trade-offs rather than pretending there are none.

The biggest example of this is the assumption that most NHS problems would be solved by more money rather than by spending the current budget more effectively.

Another is that NHS improvement strategies set out to achieve too much, rather than to focus on a narrow enough area in which it is possible to corral the necessary effort to get a result

But the problem goes far beyond these factors.

The capital spending vs more staff dilemma

Perhaps the most archetypal example of the failure to confront hard choices was illustrated by Richard Meddings, the NHS England chair in the FT last week.

He admits something that is widely acknowledged by most serious observers and analysts: that the NHS has a serious deficit in capital spending and that this limits the system’s ability to do more work or achieve higher productivity.

What he doesn’t admit is that underspending on capital is a result of a long running failure to make hard and uncomfortable choices within the available budget. For most of the last 20 years the NHS has chosen to bail out hospital deficits and recruit more staff rather than spend more on capital projects.

The system gets more staff, which is great for government press releases, but the deteriorating nature of the environment in which they work means that every extra increment of staff is less productive. This is, ultimately, a death spiral as the need for even more staff to compensate for the lack of productivity of the last increment leads to even more pressure on the capital budget.

Many argue the problem is that the overall budget needs to be bigger to allow for more capital spending. However, the post-covid budget increase (the biggest ever in a single year) led to a big boost in staff numbers rather than a big increase in capital spending.

The real problem is a widespread failure to make the hard choice to recruit fewer staff and spend more on capital.

A similar problem occurs when the system must choose between capital spend on maintenance or on new capacity. Forty new hospitals makes a better headline, but the choice to focus spend there results in spending less on tackling the huge maintenance backlog — further undermining productivity.

The more staff vs a better mix of staff trade-off

There are several other staff-related choices where the failure to choose carefully is a major problem.

Is it better to have a higher headcount or to spend more on retaining the experienced staff the system currently has? Many parts of the NHS usually choose the headline-friendly “more” rather than the, arguably better for productivity, retention. More staff often comes at the cost of deranging the skill mix of clinical teams. And the system often chooses more front line staff when more support staff or, shock horror, more managers might do more for productivity.

This problem also applies to the staff balance across the system. The NHS has long said it needs more capacity in primary care. But it has chosen to expand hospital staffing quickly while GP numbers decline. The overall trade-off risks the future of primary care and doesn’t look good for the long-term health of the system as a whole.

The NHS is also failing to invest in adequate numbers of digitally-skilled staff and analysts. They are essential for improving productivity and for delivering the supposed benefits of new technology spending. But the draft workforce plan for those staff recoils from the obvious solution reached by the Hewitt report that the service should pay them competitive market salaries and exclude them from AfC salary bands which are ludicrously low.

Paying them outside AfC might upset too many other staff on AfC grades so the draft plan avoids the hard choice that might fix the problem.

Many hospitals leap to hire more front line staff to solve operational capacity problems that are the result of badly designed or coordinated processes. The alternative choice would be to spend the money on more operational management capacity to fix the broken processes. Too many make the easy choice, not the right choice.

Spending on shiny new technology rather than infrastructure

Artificial intelligence is, allegedly going to transform work. It is certainly a sexy thing to invest in and the promise of radical transformation in treatment and productivity sounds attractive. Isn’t that why NHSE have brought Tim Ferris back?

But if the choice is to pursue investment in fancy software rather than to spend making the basic IT infrastructure solid enough to exploit it, then the result will be more waste. The hard choice would be to fix the basic infrastructure where many NHS computers struggle to run modern software and take forever to boot up in the morning. The NHS often tries to put a Formula One skin on the chassis of a 25-year old Ford Escort.

The NHS is poor at recognising the trade-offs involved in its choices of how to spend its budget. It all too often makes short-term decisions that hurt its long-term health and productivity. Deep reforms in the decision making culture are needed.