Everything everywhere in the NHS is about productivity. Staff growth since 2019/20 is over 20%, but treatment activity has stayed basically flat. The NHS went from good value to poor value really fast.

The instinct from the centre is familiar. Freeze recruitment. Ban colour printing. Squeeze agency costs. Send in auditors at seven-figure fees to tell providers what they already know: spend less. Benchmarking exercises promise that every trust can reach the top decile if they just follow the blueprint. Mathematically, someone has to ask who is left in the other nine deciles if the impossible actually happened.

But here is where the argument usually stops. And it is where we think differently.

At STRASYS, the Decision Intelligence engine for healthcare, we have analysed over 3 billion data points across one Integrated Care Board, triangulating finance, quality, workforce and activity. The analysis showed something the standard productivity equations miss entirely. When you start with consumer and population need, rather than supply-side pressure, it is possible to reshape services that improve clinical outcomes while lowering the cost of care. Not in theory. In practice. Across a whole system.

The business model is the problem

The NHS workforce plan says we need an additional 300,000 clinical staff by 2036, adding at least £25 billion annually to the wage bill. That plan assumes the 76-year-old business model is fit for the rest of the century. It is not.

The evidence is hiding in plain sight. During junior doctor strikes, something remarkable happens. Consultants move to the front of patient flow. Admission avoidance improves because senior decision-makers see patients directly. Wards empty. Emergency departments run without corridor waits. The system becomes reliable. Not because people work harder, but because resources sit in the right place for the right decisions.

Then the strikes end and everyone goes back to how things were. Nobody asks why.

The system, as it is organised, generates demand into the wrong hands. It then keeps demanding more of everything. More staff, more money, more buildings. But more of the same inside a broken model just widens the productivity gap.

Squeezing produces dust, not value

The cost control playbook is as familiar as it is ineffective. Our CEO Naeem Younis has written extensively about why Cost Improvement Programmes do not work. We analysed NHS acute providers from 2012 to 2017, examining financial, regulatory, quality and operational performance in light of CIPs. The pattern is consistent: salami slicing shows a shift on the spreadsheet, but the costs eventually exceed the agreed control total. Because the system generating the problem is unchanged.

We have seen this up close. Trusts running on vendor debt, where the cash flow looks healthy only because monies owed are retained so long that private suppliers stop delivering goods. Chemotherapy drugs withheld because the hospital had not paid the vendor. Clean laundry supplies down to two days of surgical cover. The auditors arrive, at significant cost, and the reported deficit doubles overnight.

The regulator squeezes the provider. The provider squeezes its vendors. The crisis breaks. The board changes. And the cycle continues.

None of this addresses the fundamental question. How should NHS resources be allocated to actually meet patient and population needs?

Starting from need, not supply

This is what our Workforce Decision Intelligence product was built to answer. Not "how many staff do we have?" but "what do our patients need, and how should we organise our people and resources to meet those needs?"

Through our work with NHS trusts and systems, using DuPont decomposition for NHS economics, five-year ratio analysis, and population need segmentation, we have shown that the productivity challenge is not about effort. It is about the model.

Changing the business model starts with understanding patient and population needs to inform the reshaping and reallocation of existing resources. Understanding needs is not the same as "we keep the patient at the centre of all we do." It demands data, analysis, and the capability to translate insight into confident decisions. That is what Decision Intelligence does.

The alternative is to carry on. Trapped in Enoch Powell's 1960s policy of the District General Hospital as the unit for delivering everything for everyone, everywhere. Spiralling into mediocrity, at best.

It is a choice.