Dr Niamh Thompson
Principal Policy Advisor
The NHS made historic productivity gains of 15% between 2010 and 2018. Policymakers shouldn’t forget that these were fuelled in part by discretionary effort and that basic improvements in workforce management could help it rise again.
NHS productivity finally looks to be recovering, but hospital productivity remains substantially lower than pre-pandemic levels.
Discretionary effort – staff going “above and beyond” – has always been vital for productivity, but there “has been a marked reduction in discretionary effort across all staff groups”, according to Lord Darzi’s report into the state of the NHS. This has likely contributed to lower health sector productivity since the pandemic.
Despite this, the NHS workforce plan hinges on ambitious annual productivity gains of 1.5-2%, surpassing even the highest historical averages – a target critical for meeting demand with current staffing plans. Resources have gone up, but outputs remain stubbornly below 2019 levels. To achieve the 2% productivity target set by Rachel Reeves, strategic investment in technology and capital infrastructure is undoubtedly an essential step toward recovery. A lesser discussed point is how to improve workforce management to unlock further productivity gains.
Frontline conditions
Working in frontline NHS services for 5 years as a doctor, I had many occasions to ask colleagues in clinical work if something was wrong. Usually, the hint was finding them crying in a store cupboard.
In the spring of 2020, during the first wave of the pandemic, I found myself watching a colleague’s behaviour with alarm for a very different reason: one of the most exacting consultants in the Emergency Department – known chiefly for their scowl and sharp turn of phrase – had come into work whistling.
They handed out coffees to peers. They smiled. Curiosity, if not concern, got the better of me. “You seem in a good mood today?” I enquired. “I am! I’m quitting. I can’t go back to the way it’s been in the last few years.”
Our usual workload of stroke, chest pain, head injuries, stabbings, and more had decreased dramatically during the COVID-19 pandemic as patients avoided hospitals and resources were poured into the front line.
The result was surprising: a well-staffed emergency department with ample resources to meet moderate demand. My consultant felt the surprising effects of this eerie calm, and he wasn’t the only one.
Taking stock after the pandemic
The extensive discussion around the NHS’s productivity problem has focused on under-investment, particularly in capital infrastructure and technology.
If discussing the workforce, it’s usually in the context of burnout post-COVID. That’s a valid but separate point. The experience of my consultant points to something else, too.
Demand had been rising for over a decade, gradually worsening pressure on frontline workers, and then the pandemic hit. For some, particularly those in the acute care sector, the “crisis of a generation” provided an unexpected respite, forcing them to take stock.
The pandemic shone a light on our ways of working and made it harder for some to return to business as usual. For some, this meant leaving the service. For those taking less drastic action, it looked more like approaching work differently.
Other sectors have characterised this as “quiet quitting”. Research from LSE found that compared to 2019, those with a degree worked 60 hours less during 2022. In the case of the NHS, this phenomenon may now have illustrated just how high discretionary effort had been before the pandemic.
To explore the importance of working culture to the NHS productivity puzzle, we tracked key workforce metrics against productivity during austerity and then into the pandemic. It revealed some important trends.
The NHS has enjoyed remarkably high levels of discretionary effort.
Understanding how discretionary effort—staff going “above and beyond”—relates to productivity is essential, even amidst uncertainty. Using proxy measures, we analysed unpaid overtime as an indicator of discretionary effort and compared it against survey data on staff feeling valued at work. These metrics, plotted alongside NHS productivity, reveal an interesting relationship.
Between 2010 and 2015, the NHS experienced austerity measures, with health system inputs growing only about 2% annually. This effectively amounted to real service cuts amid rising patient demand and an ageing population. Yet outputs increased at an average annual rate of around 4%, resulting in substantial productivity gains. This was achieved in part by a nearly 15% rise in reported unpaid overtime by staff, as shown below.
But what’s most interesting is that during this period of exceptional challenge, feeling valued increased by 29%. This suggests discretionary effort and feeling valued at work rose in tandem throughout this difficult time – before the additional burden of the pandemic. So it is not about avoiding hard work—NHS staff are capable of managing challenges. It does, however, indicate that the workforce was in a particularly difficult place before COVID-19 struck.
Figure 1: Relative proportion of staff recording unpaid overtime and “feeling valued” by their NHS employer from 2007/08 to 2014/15. Quality-adjusted productivity Index (FYE 1996 = 100) for the NHS for the same period. (Source: NHS survey data and Office for National Statistics.)
| 1. Unpaid overtime is a crude measure influenced by several other factors (including availability of paid shifts). Still, it underestimates the acute care sector rates – where the most overworked people have less time to complete these surveys and record their unpaid overtime.
2. An important caveat is sampling bias in these surveys. For example, NHS leavers are likely underrepresented. |
NHS staff survey data also suggests that what my Emergency Department consultant experienced during the COVID-19 pandemic might not have been an isolated phenomenon.
In 2020/2021, productivity dropped sharply as resources were poured in, but many outputs halted. Whilst unpaid overtime remained steady until 22/23¹, it was notable that staff “feeling valued” saw its largest recorded decline in this period, dropping 14% despite the public outpouring of support and additional resources.
Policymakers must reckon with this critical workforce dilemma: NHS recovery depends not only on resources and technology but on the staff who deliver care – and who must enact their intended policy reforms.
Understanding why discretionary effort dropped
To understand why, it is worth considering how the dramatic increases in inputs during the pandemic were felt by staff who had toiled in frontline care, delivering more with less for the best part of a decade. Staffing levels were prioritised like never before, at the expense of entire services.
Suddenly, the mantra “there is not enough money” was flipped – the funding flowed thick and fast. When it came to beating COVID-19, resources were thrown at the health system – both human and material. Sacrifices made throughout austerity and the pandemic itself – late nights, failed relationships, missed birthdays and weddings – were suddenly seen through the lens of this new experience, and began to look more like avoidable collateral damage than dutiful necessity.
At the same time, there were broader perspective shifts around work underway.
Non-critical workers discovered their jobs could be paused for long periods or continue entirely remotely (a shift we’ve seen endure after the pandemic). The point is that these ‘unprecedented circumstances’ have created dramatic perspective shifts across all sectors.
Fixing the decline in discretionary effort
Our discussions with Trust leaders and policy specialists found no disagreement that discretionary effort was down, even if it wasn’t possible to quantify. The bigger question was what to do about it?
In contrast to my first-wave pandemic experience in emergency medicine, during the second wave, I transitioned to critical care, where demand was at its peak. Our unit handled three times the usual number of patients in dire circumstances.
But for the first time, I enjoyed basic practical benefits like blankets, rest stations, and free meals—along with e-rostering, stable teams, and strong management—leading to the best working experience of my career.
There are no magic bullets, but it does illustrate how improving the experience of work for the NHS workforce is possible, even under the most challenging circumstances.
Pay attention to workforce management
Placing workforce management at the heart of conversations about productivity – and giving Trusts, departments and managers the flexibility to improve it – could help to shift the dial.
One practical example is the role of self-rostering systems for healthcare staff, which gives them more ability to select their shifts. A recent meta-analysis found self- and e-rostering increases staff satisfaction, improves work-life balance and, crucially, reduces turnover, although more research is needed on how to deliver it effectively.
The benefits of this are not just social – a sense of agency is beneficial for wellbeing and retention in and of itself. But many of the practical reasons for choosing your shifts also have a social component: cancelling fewer plans with friends by choosing shifts to avoid them or being able to coordinate shifts with your partner so you can better share childcare (and get more time with your kids).
Building relationships between staff
Fostering relationships is one of the most prominent themes in the literature on motivation, productivity, and discretionary effort, and structural interventions like e-rostering can help create these less immediately obvious benefits.
Soft defaults in e-rota design can support much more consistent shift teams, fostering relationships between staff. Having a close friend at work is one of the strongest predictors of productivity and retention, while having a good relationship with your manager is the top factor in employees’ job satisfaction and is strongly linked to both performance and productivity.
In an analysis of over 1m responses to Gallup surveys, simply considering your manager a “partner” rather than a “boss” was as good for wellbeing as a 30% pay rise.
While many drivers of discretionary effort vary by gender and ethnicity, the importance of working in teams and having positive social relationships at work is consistent. In one small RCT, rapport-building at the start of a task increased productivity and discretionary effort.
Google famously identified similar themes when they studied 180 project teams and found that psychological safety derived from stronger relationships was more impactful than skill mix, experience, or extra resources on team success.
Social support is particularly important for protecting employee wellbeing in the face of job stress, so it should be a key focus of NHS workforce reforms.
In one randomised controlled trial (RCT), managers were simply told to do everything they could to improve the retention of their team. Despite no changes to processes themselves, turnover dropped by 20-25% (with no negative impact on productivity).
How the NHS hampers working relationships
Given the benefits, fostering positive relationships is something many organisations focus on. And yet the NHS seems uniquely designed to undermine them.
Shift rotations take no account of work relationships, so staff can go weeks or even months without overlapping with their clinical lead, constantly working with new faces. These relational structures and associated benefits were arguably lost when we moved away from the old firm model of medical training.
Inconsistent teams are particularly challenging in a high-stress environment, where mutual trust is vital for staff wellbeing and, in turn, organisational performance.
This is reflected in the data from leavers. Junior doctors leaving the NHS for Australia can roughly double their pay, yet they are twice as likely to cite workplace culture and work-life balance as their reason for leaving.
It’s hard to overstate how disruptive current systems can be: a colleague was informed just before her wedding that she was scheduled to be on call, despite having tried repeatedly to book her annual leave. When she protested, she was told it was her responsibility to arrange for cover. All of this is caused by delayed delivery of rotas using outdated approaches.
Reaching pay settlements on strikes was an important step, but note that pay was always just one component of staff dissatisfaction. E-rostering is an example of a practical change that removes many of these daily frustrations and improves efficiency.
There’s much to be gained from aligning strategy on productivity with workforce wellbeing.
E-rosters are just one example, but they illustrate how a relatively cost-effective, low-risk investment can enhance productivity and morale.
As IPPR’s new report points out, incorporating staff ideas into spending decisions can increase engagement and productivity while supporting better investment.
By thoughtfully investing in technological solutions that prioritise staff benefits and remove pain points from their working day, NHS leaders could achieve substantial gains, rebuilding workforce goodwill and potentially compounding productivity gains.
In the context of the current challenges facing the service, that is low-hanging fruit that policymakers and NHS leaders shouldn’t overlook.
¹The decline in unpaid overtime in 22/23 is likely influenced by the vast hiring increases during the pandemic. This may mask significant increases in additional labour – as we know those on the front line are often too busy to complete the survey
