One of the most long-standing public policy discussions about the National Health Service revolves around efficiency: its efficiency as a health system and the efficiency of its employees. As early as 1951 officials at the Ministry of Health began assuming the service was over-staffed, circulating a memorandum that year instructing Regional Health Boards to reduce headcount by five per cent across the board. That circular, like many later efforts to cut staff costs, demanded health service managers obtain savings by improving the staff productivity without affecting care, effectively asking them to do more with less.
Such exhortations no doubt sound familiar to present day NHS staff, many of whom will have worked through several rounds of cost-cutting, all aimed at increasing productivity and reducing headcount, usually accompanied by soothing words about not harming “frontline” services.
Since the 1950s the NHS has seen various schemes of this type. The premise behind the 1962 Hospital Plan, introduced by Enoch Powell then reinforced by the 1964 Wilson Government, was that spending on new buildings and new equipment to modernise the NHS would be accompanied by better working practices and staffing reductions. Freed from inefficient old hospitals, all categories of NHS staff would be empowered to shed wasteful habits and old-fashioned ways of doing things.
Hoped for improvements were not to be left to chance. The Health Ministry’s Advisory Council for Management Efficiency hired hundreds of efficiency experts to conduct “organisation and method” studies at dozens of hospitals, examining how workers were managed. These ran parallel to “work study” programmes, where hospital workers were watched and timed during their shifts in the hope of uncovering promising areas for improving productivity.
These programmes were not uncontroversial. Acknowledging that absolute efficiency had the clear potential to adversely affect the quality of care, nurses and doctors were largely excluded from their purview. Work study was overwhelmingly targeted at support staff, particularly laundry, catering, cleaning and portering staff, under assumption that their effort could easily be intensified without cutting the clinical attention paid to the sick.
By the mid-1960s, NHS work study operatives had generated studies claiming huge reductions in these categories of staff, sometimes as much as 25 per cent, could be obtained, if new working practices were extended across the NHS.
The mechanism through which this was to be achieved was “productivity bargaining”. Trendy in management science circles in the 1960s, “productivity bargaining” expanded across British industry as a solution to low productivity and increasing numbers of strikes. Firms looked to negotiate bonuses with their workers in exchange for the adoption of new, more efficient, working methods. NHS managers and health workers’ trade unions reached a general agreement to implement bonus schemes in 1967, with the unions hoping that cash incentives would improve their members abysmally low pay. The usual caveat applied from the Ministry of Health that bonus schemes were not to be ‘injurious to the well-being of the sick’.
Progress thereafter was impossibly slow, with just 3 per cent of support staff enrolled in any bonus scheme at all by 1971. As it turned out neither managers nor workers felt that “productivity bargaining” offered them much. Desperate to achieve some kind of improvement in this area, the government’s National Board on Prices and Incomes (NBPI) recommended that hospitals implement interim schemes, where workers were offered bonuses simply for agreeing to reductions in staff numbers, echoing the crude memorandums of the 1950s.
Why were these schemes such failures? At the time, ministry officials suggested bureaucratic inertia was largely to blame. Managers were stuck in their ways and resistant to new ideas. Evaluating the failure in 1971, the NBPI Report blamed hospital administrators and heads of departments for not being ‘alive to the need to keep bonus schemes once introduced under control’. They argued ‘any incentive payment scheme decays in time unless constant attention is paid to its working’.
In their frustration, the NBPI’s investigators revealed why the outcomes of these “productivity and efficiency” programme has historically been so poor. The NHS, for all its varied practices and results, was (and is) a cheap health service and much of its workforce went above and beyond their stated work norms precisely because of their moral investment in work. Extra productivity could only be extracted by continuous management effort to win more intense effort from staff who were already stretched by the NHS’ enormous demands. Health care was labour intensive service work, the efficiency of which was difficult to measure and compare, and even more difficult to make more productive. Moreover, the distinction between “frontline staff” and every other kind of health worker was built on the fiction that support staff were somehow less vital to quality care.
“Work study” was by no means the last attempt to extract more effort from the NHS’ workforce; the 1980s saw the introduction of private sector managerialism; and in the 2000s the Blair government developed an obsession with targets and metrics as a motor for modernisation. Since 2012 Strategic Transformation Partnerships mark the latest attempt to extract more work from health workers. Future health planners might do well to acknowledge previous failures to intensify “productivity” and perhaps be a little more sceptical about the likelihood of drastically improving performance.