Detailed Summary: HSJ Health Tech Podcast – Anita Charlesworth on NHS Productivity and the Workforce Challenge

This discussion explored one of the defining issues facing the NHS over the coming decade: how to restore productivity while simultaneously transforming the way care is delivered. Although framed around productivity, the conversation repeatedly returned to workforce planning, arguing that the workforce challenge is not primarily about reducing staff numbers but about deploying people differently, supporting them better, and creating the conditions in which productivity can improve sustainably.

Several important themes emerged.

1. The NHS productivity problem is real—but often misunderstood

Anita Charlesworth began by challenging some common misconceptions about productivity. She explained that NHS productivity is not a measure of whether staff are working hard enough. Instead it is a technical measure comparing:

• the amount and complexity of healthcare delivered;

• adjusted for quality;

• against the resources used to provide it.

Using this measure, NHS productivity fell dramatically during the pandemic—by approximately 25%. Although productivity has since been improving, recovery is expected to take until the end of the current Parliament, meaning the NHS will effectively have lost around a decade of productivity improvement. Importantly, she argued this should not be interpreted as workforce failure. The NHS entered the pandemic with longstanding structural weaknesses including:

• insufficient spare capacity;

• underinvestment;

• workforce shortages;

• ageing infrastructure.

COVID exposed and amplified those weaknesses rather than creating them.

2. Productivity is not simply about doing more

A major theme throughout the discussion was that traditional measures of productivity are too narrow. Historically, success has often been defined as treating increasing numbers of patients with relatively stable resources. Charlesworth argued this definition is no longer sufficient.

Instead, productivity should increasingly be judged by whether the NHS is:

• improving population health;

• preventing illness;

• delivering better outcomes;

• using scarce resources in ways that maximise health gain.

Simply increasing activity is no longer enough. The NHS therefore needs to shift from measuring:

"How much healthcare are we delivering?"

towards asking:

"How much health are we creating?"

This distinction underpins much of the workforce discussion.

3. Failure demand is consuming enormous workforce capacity

One of the strongest workforce messages concerned what Charlesworth described as "failure activity" (drawing on the work of John Seddon and others). She argued that large amounts of staff time are spent dealing with work that should never have existed in the first place.

Examples include:

• unnecessary follow-up appointments;

• duplicated assessments;

• poor patient flow;

• administrative rework;

• delays created elsewhere in the system;

• discharge bottlenecks;

• fragmented care pathways.

This work keeps staff busy without adding value. Consequently, many NHS teams appear extremely busy while producing relatively little additional health gain. The solution is therefore not asking staff to work harder. It is redesigning systems so staff spend more of their time delivering value rather than correcting failures.

4. The productivity challenge is fundamentally a workforce planning challenge

Rather than treating workforce planning as simply forecasting headcount, the discussion presented productivity as depending upon how well workforce planning addresses four interdependent issues.

These are:

Capital investment

The NHS has underinvested for many years in buildings, equipment and digital infrastructure. Poor environments reduce staff productivity regardless of individual effort.

Workforce investment

The NHS has repeatedly failed to train sufficient staff, leading to heavy dependence upon temporary staffing and international recruitment. The result has been:

• fragmented teams;

• inconsistent skill mix;

• continual recruitment pressures.

• Technology adoption

The UK generates considerable healthcare innovation.

Its weakness lies in adopting innovations consistently and at scale. The next decade will present significant opportunities through:

• AI;

• voice recognition;

• automation;

• digital pathways;

• predictive technologies.

However, technology alone will not improve productivity. Success depends upon redesigning jobs, workflows and workforce skills.

Leadership and management

Perhaps the strongest message was that leadership capability has become an overlooked productivity asset. Managers increasingly spend time on:

• reporting;

• assurance;

• compliance;

• monitoring.

rather than service transformation. Leadership therefore becomes focused on administering the current system instead of redesigning it.

5. Boom-and-bust workforce planning has become one of the NHS's biggest structural weaknesses

Charlesworth was particularly critical of cyclical workforce policy. She described repeated cycles whereby government:

• suppresses workforce growth;

• subsequently recognises shortages;

• rapidly expands recruitment;

• later attempts to reduce staffing again.

This "boom-and-bust" approach creates significant inefficiencies. Following COVID, NHS staffing increased by around 25%. However, organisations were not simultaneously provided with:

• workspace;

• equipment;

• supervision capacity;

• training infrastructure;

• time for team development.

Consequently, organisations were expected to absorb very large numbers of new staff without corresponding investment in organisational capability. Predictably, productivity initially fell.

Rather than interpreting this as evidence of overstaffing, Charlesworth suggested it reflects poor workforce planning.

6. Workforce numbers alone are the wrong debate

One of the most important planning messages concerned the current political focus on overall staffing numbers. Charlesworth argued that asking whether the NHS employs too many or too few staff misses the real question. Future workforce planning must instead consider:

• which professions are required;

• which skills are needed;

• where staff should work;

• how technology changes roles;

• how services are organised.

For example:

The NHS has expanded specialist hospital capacity much faster than primary care capacity. If policy genuinely intends to move care into communities, then workforce planning must rebalance skills accordingly. The challenge therefore becomes one of workforce composition rather than simple workforce size.

7. AI changes workforce planning—but does not eliminate the need for staff

Technology featured prominently. Charlesworth suggested current technological developments differ fundamentally from previous waves of innovation.

AI is likely to:

• remove administrative tasks;

• automate routine processes;

• alter skill mix;

• support clinical decision making.

However, she rejected simplistic assumptions that AI will replace large numbers of healthcare workers. Instead, technology is more likely to augment staff capability.

This creates important planning questions:

• Which tasks disappear?

• Which new skills emerge?

• Which roles change?

• How should education adapt?

The implication is that workforce planning must increasingly become dynamic rather than static.

8. The NHS has too much compliance and too little freedom to innovate

An especially striking example concerned surgical pathways. According to evidence cited during the discussion, the number of mandatory compliance steps for a straightforward surgical pathway has increased from approximately 46 steps to

265 steps over two decades. This illustrates how increasing regulation gradually reduces staff autonomy.

The consequence is that clinicians spend more time satisfying processes than improving services. Charlesworth argued productivity requires organisations to have greater freedom to redesign care locally.

9. Payment systems currently reinforce activity rather than outcomes

A significant part of the discussion focused on financial incentives. The existing system largely rewards activity. This works reasonably well where standardised procedures dominate. However, modern healthcare increasingly involves:

• multimorbidity;

• prevention;

• integrated care;

• neighbourhood services.

These require different incentives. The proposed direction is towards:

• outcome-based funding;

• year-of-care payments;

• population budgets;

• local accountability for health improvement.

Such models encourage organisations to optimise whole pathways rather than maximise individual episodes of care.

10. The workforce challenge is primarily about transformation, not cost reduction

Charlesworth repeatedly emphasised that productivity should not be confused with short-term financial savings. Many current productivity actions involve:

• delaying recruitment;

• vacancy freezes;

• reducing headcount;

• postponing investment.

These may improve annual financial performance but rarely improve long-term productivity. Instead, sustainable productivity depends upon:

• redesigning care pathways;

• improving patient flow;

• removing failure demand;

• adopting technology;

• changing workforce deployment.

This requires long-term investment rather than annual cost-cutting exercises.

11. The psychological contract with NHS staff must be rebuilt

Perhaps the strongest workforce message came towards the end of the discussion. Charlesworth argued that transformation cannot succeed without an engaged workforce. She distinguished engagement from satisfaction. Staff do not necessarily need to be comfortable.

They do need to:

• trust leadership;

• believe change has purpose;

• feel equipped;

• feel valued;

• have confidence that new ways of working improve care.

The indirect costs of poor industrial relations, low engagement and broken trust are likely to exceed the direct financial costs associated with industrial action. Rebuilding that relationship is therefore central to productivity.

12. Leadership capability becomes a strategic workforce priority

The discussion concluded that future workforce planning cannot focus solely on clinical staffing. The NHS will increasingly require capability in areas such as:

• systems engineering;

• service redesign;

• data science;

• digital implementation;

• AI deployment;

• organisational development.

Leadership itself becomes part of workforce planning. Managers require:

• greater capability;

• more freedom;

• clearer accountability;

• permission to innovate.

Without this leadership capacity, technological and organisational change is unlikely to succeed.

Overall conclusions

The discussion reframed NHS productivity as fundamentally a workforce planning challenge rather than simply a financial or operational issue. The speakers argued that the NHS should move away from viewing workforce planning as forecasting headcount requirements and instead treat it as the strategic design of future healthcare delivery.

The emerging model requires workforce planning to become:

• system-based rather than organisation-based, recognising that workforce decisions must optimise whole care pathways rather than individual providers;

• skills-based rather than numbers-based, focusing on the capabilities required rather than simply expanding or reducing staffing establishments;

• technology-enabled, redesigning roles around AI, automation and digital tools rather than assuming technology alone creates efficiencies;

• prevention-oriented, supporting the shift from hospital activity towards neighbourhood, community and preventative care;

• focused on eliminating failure demand, so staff spend more time creating value and less time correcting avoidable system failures;

• supported by strong leadership, capable of redesigning services rather than merely administering existing processes;

• underpinned by staff engagement, recognising that sustainable productivity depends on trust, capability and a renewed psychological contract between the NHS and its workforce.

Perhaps the most significant insight was Charlesworth's insistence that productivity is not about asking people to work harder. Instead, it is about giving staff the tools, systems, technology and organisational conditions that allow them to spend more of their time delivering high-value care. In that sense, improving productivity and improving the working lives of NHS staff are presented not as competing objectives, but as two sides of the same challenge.