Waste not, harm not: The moral case for efficiency and productivity in healthcare (part 3)

Summary

This is the last of three articles where Professor Clive Deadman argues that driving modernisation and productivity improvements in clinical care is a moral necessity. It examines why unwelcome change is so difficult to implement and considers solutions for our NHS. It contains extracts from the recently published ‘Risk, opportunity & Performance: The art of taking worthwhile risks'.

Content

The story so far

In the previous two articles, I looked at what makes medicine so different from all other human activity. Its complexity makes performance management difficult. I looked at the quality of management information in our NHS. There is an enormous amount of it but it is insufficiently robust to justify difficult decisions, such as the reallocation of resources from one area to another. In the search for solutions, I examined how other, less complex, industries have modernised and delivered enormous benefits for customers. These innovations have doubled human life expectancy and financed and equipped modern patient care.

In the UK, Lord Darzi recently published a thoughtful review into the state of our NHS. He observed that the NHS was an unhappy workplace and there had been a long term decline in productivity.[1] He detailed 28 excellent findings and recommendations. Many of these recommendations have been made before and implementation has failed. Albert Einstein is credited with saying:

“Insanity is doing the same thing over and over again and expecting different results.”

If there was an easy solution it would have been done long ago, so inevitably it will be difficult and perhaps very uncomfortable for some of us.

Why does this matter now?

Unless you have been living in a cave, you will have noticed almost all nations are running out of money and accumulating debt to an extent never experienced in global peace time. Historically, healthcare has been seen as a priority that should be funded. That has been a good and necessary choice. At some point healthcare must be able to demonstrate value for money if it is to attract the funding and public support it needs. I believe we are coming to that point now.

What is the value of a life?

Some say a human life is priceless. But is it? In the UK/Europe, under some circumstances, a human life is worth approximately $3m each. In the USA, humans are three times more valuable.  In sectors where the public is wholly passive (preventing mains gas explosions, air travel and radiological safety),  human lives are up to 20 times more valuable. This confusing picture shows how difficult it is to manage human and patient safety. Confusion, blame and fear might be useful primeval instincts, but they can drive unwelcome outcomes in a modern industrialised society.

Confusion, blame and fear

Blame and fear of making errors are major drivers of caution. It is a global phenomenon that many medical decisions, and a significant proportion of patient deaths, could be judged ‘avoidable’. Many clinical choices must be made quickly, sometimes with incomplete information. Ironically, rare and complex clinical symptoms occur more frequently than might be expected. With the benefit of hindsight it is often possible to think of new investigations or choices which could have improved patient outcomes. This is of particular concern in medicine due to its complexity.

Research in 1974 by Fischhoff and Beyth, published under the title “I knew it would happen”[2], demonstrates that human bias makes it exceptionally hard for participants to remember or rationalise the uncertainty and confusion that previously existed. During reviews into events, the confusion and uncertainty that existed before the crisis has largely evaporated. All that remains is the certainty that, with hindsight, mistakes were made. Patients and regulators often do not understand this, and investigations and reviews can become a major driver of risk aversion, slow decision making and a reluctance to drive through change. These behaviours can put tomorrow’s patients at greater risk. If we are to deliver the productivity improvement and change needed, these realities need to be more widely understood.

What actually needs to change?

Implementation of the 28 Darzi recommendations will not be possible without a fresh approach. In any workplace or industry, adding resources is always welcomed; however, business change and withdrawal of resources are often resisted by some. We must find better ways to make the association between the cost of withdrawal of resources in one area and the benefits of relocating them elsewhere. And there are numerous examples where we are failing to do this well:

• Covid-19 lockdowns: Most nations have unresolved debate about how well pandemic lockdowns were handled. In the UK, there were valid reasons for tighter or more relaxed public health measures. Perhaps expecting perfect decision making  in such circumstances is unrealistic, but scant consideration of the long-term social, educational and economic costs of these measures shows a balanced consideration was too sensitive to be attempted.
• Quality impact assessments (QIA): Most jurisdictions follow some sort of risk assessment processes when making changes to healthcare provision. In the USA they are called QIP. In the UK they are called Quality Impact Assessments (QIA). QIA guidance is helpful[3] but still requires a ‘holistic view of quality’ that is limited to the scope of the change in services required. Mitigations are required for any risk of service deterioration and, for important changes, continuous and complete consultation is required. Everything needs to be documented, and appropriately senior people need to be accountable for the consequences of any decisions. This can amount to almost anybody having a right of veto over a change and any major change is unlikely to be approved unless massive unopposed consultation has occurred. Surveys show a significant proportion of NHS staff have reservations over the efficacy and safety of vaccinations. With 1.4m employees, it is inevitable there will be decision makers with strong and opposing views on most issues. Whistleblowing and proper consultation with clinicians is essential, but a stronger resolve to modernise and implement improvement is needed.
• Physician Associates (PAs) debate: PAs are physicians with less training than doctors. The role was created in the USA in the 1960s and 50 countries make use of such roles. Their increased use in the NHS has recently resulted in some toxic debate. A significant proportion of PAs—with women and minorities overrepresented— have reported workplace bullying. An independent review by Professor Gillian Leng was initiated to objectively understand matters.[4] This thoughtful review has been helpful in restoring some objectivity to the debate. One observation Professor Gillian Leng made was that the strongest critics of the use of PAs came from the most junior clinicians and those who had less experience of working with or supervising PAs. The review noted that several PA misdiagnoses may have contributed to six patient deaths. If true, that is deeply distressing. Given that delays in A&E and cancer treatment cause thousands of avoidable deaths, it is concerning that critics of PAs ignore their role in improving patient flow and access by expanding NHS clinical capacity.

What do we do next?

These are extremely uncomfortable matters to discuss. Even though medicine is incredibly complex and inevitably mistakes are made all the time, I can’t imagine how I would justify the death of a family’s loved one because of a PA misdiagnosis. However, the considerations we are making, the public debate and comment is incomplete. We are quite correctly focused on the safety of patients in our care who might be put at risk from modernisation and change, but insufficiently attentive to the thousands of unnamed patients with cancer and A&E patients who will unnecessarily and certainly die in the near future because change and improved productivity has not created the capacity to treat them as quickly as other health systems do.

We don’t want our NHS run along wholly business values. The Francis enquiry into the Mid Staffordshire NHS Foundation Trust scandal tells us that.[5] We need to keep the good things. The NHS is full of hard working people, and when patients finally get access to care it is invariably kind and good. However, there is a moral need for improvement.

Rather than marginalising performance management, we should be excited about the prospect of improved NHS productivity.

Clinicians’ bonus payments should be linked to their productivity. If a change releases funding, we need to look at the patient safety benefits that this funding can generate elsewhere. All other industries, which are less complex than medicine and fortunate not to deal with human life, have managed to do this already. They have become more productive, employ happier staff and have access to better equipment and business systems than our NHS. What we are doing is neither fair nor right.

It may require changes to our culture, processes and the law. Clinical leaders are some of our brightest and visionary thinkers. They all have lists of improvements that should have been implemented years ago, but someone, somewhere, has managed to stop them. The leadership challenge will be immense. Some vested interests will be determined to keep the status quo. They will continue to use fear of specific failures and investigations to prevent substantial, worthwhile, and widescale improvements. But we have tried everything else and it hasn’t worked.

References

1. Department of Health and Social Care. Summary of Lord Darzi Letter to Secretary of State for Health & Social Care, November 2024.
2. Fischhoff B, Beyth R. I knew it would happen. The Hebrew University of Jerusalem, Organisational Behaviour & Human Performance, 13, 1-16:1974.
3. NHS England. Quality impact assessment -framework and tool, 24 June 2025.
4. Leng G. Independent review of the physician associate and anaesthesia associate roles: final report. Department of Health and Social Care, 16 July 2025.
5. Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, Chaired by Robert Francis QC, February 2013. ISBN 9780102981476.

Blogs in the 'Waste not, harm not' series:

• Part 1
• Part 2 
• Part 3

About the Author

After starting work as an engineer in Africa, Clive spent 9 years in private equity/corporate finance and then 20 years with United Utilities and Electricity Northwest.

In recent years Clive has worked as and Chair, Audit & Risk Chair and Non-executive Director for a range of organisations, including the NHS and several social housing providers. He is continually researching and writing and is a Professor of Water and Energy at Cranfield University.