Just about every NHS acute hospital is trying to weather a perfect storm: massive deficits and deteriorating performance on a scale that makes previous crises look like logic puzzles. The response is always the same. Cut emergency department wait times. Cut elective care wait times. Cut spending. The first two demand more spending. There is not only no more money, there is less money. Yet the NHS budget has exploded, productivity is the problem, and performance has never been this bad.
The pyramid game
When deficits balloon, emergency actions follow. No more pencils, pens, and post-its. Vacancy freeze. Agency cuts. And a promise, stated as rigidly as a manifesto pledge: frontline clinical staff are safe from any cuts.
Then the maths arrives. A £60 million hole requires staff cuts. At £150k salaries, that is 400 people. At £100k, 600. At £60k, 1,000. At £30k, 2,000. Imagine those numbers as a pyramid. Your job is to slim it down.
Decimate the foundations and the structure wobbles. Hospitals fill with friction, frustration, and fury. Morale tanks. People quit. Waiting lists grow. The pyramid game never ends well.
The question that dare not be uttered: do we have the right number of orthopaedic surgeons, cardiologists, nephrologists? If a trust leadership cannot answer that question, it has no chance of escaping the storm.
The merger that destroyed value
In 2015, three district general hospitals in one region began the argument for a merger. It was given a name built on the idea of manifestation: the Success Regime. The merged trust came to life in April 2020, serving 1.2 million people with 15,500 staff and an £850 million operating expenditure.
At STRASYS, the Decision Intelligence engine for healthcare, we tracked what happened using the Strasys Value Index, which measures how effectively trusts deliver high-quality, timely healthcare relative to cost. In 2018, before the merger, the three trusts individually and collectively were generating really good value for every £1,000 spent. Nationally, they were 7th best.
After the merger, value generation dropped like a stone. The new trust bottomed out at 86th in 2023. There was an improvement to 68th in 2024. But the trajectory tells the story: bigger was not better.
The trust could, if it were minded, extract £166 million in trapped value by getting back to the efficiency and value level it achieved in 2018 when it was 7th best in the country.
Mark Jennings at STRASYS has published the analysis of how provider groups can avoid this trap. The lesson: bigger works only if each building stops doing everything for everyone all at the same time. Improving a few pathways will never move the needle. A radical reshape of the 21st century district general hospital would.
The right first question
The Consultant Workforce Optimisation System exists to answer the question trust leadership dare not ask: is the consultant workforce deployed to maximise value? CWOS triangulates clinical activity, job plan data, programmed activities, and financial performance to reveal where the trapped value sits.
The NHSE answer to consultant productivity is job planning. Our position, argued in detail, is that individual job planning has failed. The transparency needed for genuine team-level optimisation requires a different instrument, one that connects consultant deployment to population need and value generation, not just to time and pay.
Naeem Younis, STRASYS CEO, argues that before any trust plays the pyramid game with staff cuts, it should answer one question: what is the value generated from every consultant contract? Without that answer, cutting from the bottom while protecting the top is a gamble dressed as a strategy.