The Week

The Week 29 September 2023

Sebastian Rees
Senior Researcher

With waiting lists climbing above 7.7 million, near continuous strike action by junior doctors and consultants, and concern growing about the parlous state of the estate, NHS leaders have more than a few headaches to contend with. But bubbling away beneath the surface, the NHS faces a more slow-burning challenge — the breakdown of the operational processes which make delivering healthcare possible.

This week, it was revealed that since 2018 a hospital trust in Newcastle had failed to send out more than 24,000 letters from senior doctors to patients and their GPs containing details on hospital discharge, follow-up care, and test results after they became lost in a new computer system. A week earlier, in Lincolnshire, failures to coordinate an 83 year old woman’s discharge from hospital meant she was mistakenly taken to a stranger’s house and left to sleep in their bed.

Healthcare delivery can be a complicated logistical exercise. The NHS sees 1.6 million patients a day, employs 1.4 million staff, and must coordinate its activities with a range of other organisations, from local authorities to the prison service. Some level of process error is unavoidable.

But the increased frequency of administrative malfunction is a major cause for concern. Failures to coordinate care between different parts of the Service, communicate effectively with patients and their families, and manage processes such as admissions and discharges are core drivers of inefficiency, declining care quality, and poor patient experience.

Identifying the root causes of process failure in the NHS is not simple. It is certainly the case that the NHS invests less in administration than comparable health systems, and after 2010 while frontline NHS staffing grew, numbers working in administrative and managerial roles dropped markedly. However, the last 5 years has seen healthy growth in the number of staff working in clerical and administrative support roles (18.5% compared to a 16.5% growth in clinical staff).

The problem may lie instead with the type of administrative work prioritised in the NHS rather than the workforce itself. An increasing amount of administrative time and resource may be spent on functions such as waitlist monitoring, data collection and validation, and organisational audit, which, though important, are often designed to account to national regulators rather than directly improve patient care. Solving our administrative woes will therefore require an honest reckoning — not only with workforce capacity, but also over what the system sets as its core priorities.

On to our read…

This week, our friends over at the RSA published a report from their Urban Futures Commission on how to unleash the potential of the UK’s cities. As the commissioners note, building dynamic city regions outside of London and the South East is vital to boosting economic growth. Bringing productivity levels in the UK’s Core Cities to the level of their European peers has the potential to add £100 billion to GDP annually.

The commissioners place significant emphasis on fiscal devolution as a lever for doing so. Bringing sub-national tax revenues (currently around 6% of the total tax take) up to the OECD average (32%) is seen as key to cities developing long-term economic development plans. Once a (relatively) fringe position, fiscal-devo is quickly climbing to the top of the policy agenda. How long will it take for ears in the Treasury to prick up to its potential?