Why Is the NHS Treating Fewer Patients With More Staff?

NHS England employed 1.3 million FTE staff in 2024 — up 17% from 1.1 million in 2019 — yet the total productivity index (set at 100 for 2014) stood at just 96.8, and output per worker had fallen to 90.3 on the same index, nearly 10% below 2014 levels.^[1,2] COVID caused a genuine structural break, reducing NHS activity by nearly 20% in 2020 through cancelled elective care, infection control constraints, and staff absence. Four years on, the recovery is incomplete. The Lord Darzi review (2024) identified productivity as the central challenge and estimated that closing the productivity gap to pre-COVID levels would be equivalent to treating 1.5 million additional patients annually without additional spending — a figure against which the 7.5-million waiting list must be measured.^[3]

The productivity gap is a system-level phenomenon, not an individual failing. Ageing IT systems, estate constraints, and clinical pathways designed decades ago all contribute; a surgeon whose theatre list is cut from six to four cases by post-COVID cleaning protocols is not personally less productive, but system output falls. Germany, France, and the Netherlands recovered faster from equivalent COVID-era drops, in part because they had higher baseline capital investment in digital infrastructure — the UK spends significantly less per capita on health capital than the OECD average. Without sustained investment in buildings, technology, and reformed clinical pathways, the arithmetic of the waiting list does not balance.