Why the forward view's target is in danger of being missed

The Five Year Forward View was predicated on a significant improvement in productivity, and the Carter review set out how the NHS might approach what was always an ambitious target.

The financial settlement with the government assumed an annual 2.4 per cent improvement, with the 5YFV suggesting that a sustained annual improvement of 3 per cent could be achieved in the longer term, both of which would require a step-change in workforce productivity.

However, the first in-depth analysis of how current performance and future plans at national, STP and trust level are performing on productivity suggests performance is falling woefully short of the rhetoric.

Productivity not a priority

My analysis demonstrates that in practice productivity – particularly workforce productivity – is not a priority either at the level of the sustainability and transformation plans or for the major trusts. The analysis shows that none of the STPs provide any analysis of current workforce productivity within their footprints or details of how it will be improved by their plans. Ten of the 44 published STPs make no mention of productivity at all.

“Only one of the 10 largest acute hospitals in England, which have combined revenues of more than £10bn, has so far implemented Carter’s recommendations, published in February 2015, to report progress on unit costs.”

Although the trusts typically report on well over 100 performance indicators, none look at workforce productivity, reflecting the performance management regime determined by NHS Improvement.

The impact of technology is uncertain

The 5YFV’s highly ambitious target assumed significant impact from new, digital technology. This was despite the evidence of the last 20 years that casts considerable doubt as to the productivity benefits of the digital technologies programmes that the NHS in England have chosen to implement. As in the past, the STPs focus on ‘enabling’ technologies and on the ‘digitisation’ rather than the replacement or disruption of existing working practices and processes.

All 44 STPs aim to develop an integrated share patient record, accessible through a patient portal. All are committed to support telehealth, e-consultations e-booking of appointments and the introduction of apps to support self-care and healthy living. And all are looking to extend their data analytics capability.

Digital, information rich, providers are already available as alternatives to traditional primary and community care suppliers

These developments may well deliver desirable quality, safety and experiential benefits to both patients and carers. They may also support the universal intent towards service integration and organisational consolidation, however scant the evidence that either of these approaches will deliver improved provider performance. But none of the STPs explain how these programmes will be translated into a transformation in workforce productivity, or at what investment cost and in what timescale.

This is despite the evidence that transformational technologies in each of these areas is already available and implemented – but rarely by the NHS. Digital, information rich, providers are already available as alternatives to traditional primary and community care suppliers for urgent care, chronic care, care of elderly and sexual health.

Operational support and logistical systems have been commonplace in other industries for many years. As an information based science, medicine is particularly well-suited to a revolution in decision-support that would transform the work force skill mix.

The 5YFV target will not be achieved

The lack of focus on productivity and the inherently conservative approach to technology reveals both the underlying priorities and the realities of the NHS. There are few obvious benefits to NHS organisations from productivity improvements when compared with the potential difficult consequences. There are institutionalised, professional barriers to radical change. And there is a systemic concern with organisational self-preservation.

Quite reasonably most frontline NHS organisations are focused on the immediate issues of resource constraints and demand growth. They are relatively unconcerned with a sub-optimal productivity performance. These priorities almost certainly reflect those of the general public, anxious to preserve services largely as they are, rather than face the prospect of disruption.

However, if the current approach to productivity improvement and digital technologies remains in place, there are three likely outcomes. First, the productivity aspirations set out in the 5YFV will not be achieved, other than by the simple and draconian expedient of limiting NHS resources, as demand rises.

Second, in the longer term the NHS will continue to lag behind the economy as a whole on productivity growth and will therefore require an ever increasing share both of GDP and of public spending. And third, the inevitable digital revolution in health and well-being will happen beyond the boundaries of the NHS, with potentially profound implications for its future role.

It could be different

It could be different but that would require some radical changes. The potential of the technology and the needs of the patient would have to determine the design of the new service, rather than existing working practices and processes. The NHS workforce would have to become much more flexible, with significant changes in professional structures. Greater diversity in the form and nature of services would have to be tolerated. Patients, as consumers would have to be encouraged to become much more demanding. Payment mechanisms would have to incentivise new services.

Such a technology driven transformation, as seen in so many other service industries, would require political will and leadership. However difficult the current NHS ‘crisis’ is, we are probably still far from seeing politicians prepared to take the risk.

Kingsley Manning is the former NHS Digital chair. The complete paper and full analysis, Productivity, Technology and the NHS is available to download here.