... and is the NHS really comparable to a string quartet?
First published in December 2019.
Shortly after Lord Skidelsky delivered his report looking into the feasibility of reducing working hours, Labour announced that it would introduce a 32-hour working week within ten years. It didn’t take long for the Conservatives to dismiss the idea as “a cost the NHS can’t afford”, claiming it will cost the health service an extra £6 billion a year.
Historically, growth in productivity and real wages have led to lower working hours. But both have recently stalled, particularly since 2008, with a sustained period of declining productivity in the UK.
Healthcare is labour intensive, so productivity increases are even harder to achieve. In the 1960s, two Princeton professors, William Baumol and William Bowen, pointed out a productivity problem in the performing arts. Their argument, simply put, was that the number of musicians needed to play a Beethoven string quartet is the same today as when it was written, whereas in manufacturing industries, automation has increased productivity immensely. So the costs of performing arts increase over time relative to other sectors, justifying public subsidy.
In healthcare, this theory (labelled by Baumol the “cost disease”) applies on a much bigger scale. Around the world, healthcare costs have risen faster than general inflation, taking an increasing share of national economies, exactly as Baumol predicted over 50 years ago. NHS workers are unlikely to be able to reduce their working hours by increasing labour productivity. Just as we expect a string quartet to contain four musicians, we continue to expect healthcare from teams of health professionals.
NHS workforce statistics give a rough estimate of what might be needed to move to a 32-hour week. In total, the NHS in England employs over 1.25m hospital and community staff (including 123,000 doctors, 349,000 nurses and midwives), 45,600 GPs and 140,000 other primary care staff. This equates to 1.1m full-time staff in hospital and community health services and 133,000 in primary care. Assuming 37.5 hours a week full-time (an underestimate for many), staff provide 46.25m hours of work.
Achieving the same contracted hours with a 32-hour week requires another 190,000 full-time staff, including 18,000 hospital doctors, 47,500 nurses and over 5,000 GPs. Many healthcare professionals work part time, and if this continues there could be even more need for new staff.
An imperfect analogy
These challenging figures are, of course, over-simplistic. Improving productivity is not as difficult in healthcare as in performing Beethoven. The NHS has demonstrated increasing productivity since 2002, although this has recently relied on wage restraints.
The NHS long-term plan includes several areas for improvement. Digital technology could challenge the “cost disease”, but evidence of this up to now has been limited. In general, technologies work best alongside clinical contact, rather than as a substitute, but this could still create improved productivity if clinic time is reduced.
Working shorter hours could also improve staff retention, a key issue for the future workforce. And there is growing evidence that long NHS shifts are associated with higher rates of sick leave. Again, this could be improved by a shorter working week, although not without reverting to more traditional shift patterns.
And finally, a shorter working week might mean that some staff simply get more done. Lord Skidelsky’s report cites the 1973 three-day working week that reduced time input by 40% but outputs by only 10-20% – although this was temporary and the constraints did not affect healthcare.
Real people still needed
There are reasons for the NHS to consider a shorter working week. Many staff already work part time, and a shorter working week for all could improve recruitment, retention and sickness absence. Productivity can be improved, perhaps by developing technology. But it is hard to imagine the NHS ever being less than highly reliant on real people. Healthcare will continue to be labour intensive and consequently will continue to be a “low productivity” industry.
As pointed out by Skidelsky (and Baumol 50 years earlier) this just means that public services should benefit from productivity gains in other sectors – government spending on care will and should increase over time. With or without a 32-hour working week, the cost of the NHS is likely to increase as a proportion of our national economy. Whether or not we choose to afford this is for democracy to decide.🔷
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