GUEST COLUMN:
Huw Thomas
Executive Director of Finance
Hywel Dda University Health Board
Running a modern health system means balancing quality, access, workforce wellbeing and financial sustainability at the same time, often across multiple organisations and partners.
At Hywel Dda University Health Board, we employ around 13,000 people and are responsible for planning and providing healthcare for a population of roughly 380,000 people across Ceredigion, Pembrokeshire and Carmarthenshire. We directly provide most services ourselves, run four district general hospitals, commission services from 47 GP practices, and work closely with partners across NHS Wales and beyond. It is a complex system with multiple responsibilities and relationships.
That complexity shapes how we think about productivity. It cannot simply be reduced to output per pound spent. If activity increases but patients experience worse care, longer waits or poorer outcomes, then we have not succeeded in our purpose, regardless of how the financial picture looks.
For us, productivity is closely aligned with outcomes. We increasingly talk about value-based healthcare, which considers outcomes as a function of the cost of care. The central question is how effectively we are converting money, time and professional expertise into better lives for the people who rely on us. In practice, this means focusing more on whether care genuinely improves outcomes that matter to patients, as much as we do on how much activity we generate.
In some areas of healthcare, particularly in secondary care and high-cost settings such as theatres, productivity measurement is relatively well established. In others, including primary and community care, it is more complex. Care is delivered over longer periods, continuity matters, and improvement is harder to capture through traditional metrics. That is why we are increasingly using patient-reported outcome measures to understand what matters most to patients and how they experience improvement along their care journey.
Health boards also operate with multiple bottom lines. Financial balance is one, but quality, safety, access, workforce experience and public trust are equally important. These factors interact constantly. Fragmented services, repeated assessments and delays can undermine trust, while low trust can in turn reduce productivity by encouraging duplication, siloed working and slow decision-making. Culture matters as much as process.
This is why productivity in the NHS cannot be framed as individuals working harder; it is about systems working smarter, with less waste of people’s skill, time and goodwill. Productivity improves when staff are supported, trained and trusted to solve problems. It does not improve when a system is under sustained strain. Public sector productivity cannot be about extracting more effort from people; it must be about designing systems that waste less of their expertise.
Prevention plays a central role in this. Supporting people to live well and live healthily reduces future demand on services, even though those benefits are often difficult to measure because they relate to admissions or interventions that never happen. Reducing friction within services also matters. Improving patient flow, shortening unnecessary length of stay and deploying resources more effectively can improve outcomes for patients while making better use of capacity.
Technology has a role to play, particularly in helping us understand workflows and identify blockages within the system. Digital tools now allow us to see more clearly where delays occur from admission through to discharge. But technology on its own is not enough. Improvements only work when they are combined with clinical insight and professional judgement. Delays are not neutral for patients; deterioration can occur while people are waiting, which is why improving flow is about supporting recovery as much as efficiency.
Language also matters. Productivity is not always a term that resonates with a public sector workforce, not because people are resistant to improvement, but because it can imply pressure rather than support. That is why much of this work is framed as quality improvement. Many of the quality improvement initiatives taking place across NHS Wales are, in effect, productivity improvements delivered through a focus on doing things smarter, not simply doing more.
Looking ahead, productivity is a structural response to long-term change. In West Wales, as in many rural and coastal areas, an ageing population and a shrinking working-age base mean demand for care will continue to rise. The system therefore has to become more productive by definition. That will only happen through collaboration across organisations, working with partners in place, reducing duplication and learning from each other and from industry where appropriate.
Productivity does not improve simply because the system is under pressure. It improves when people are supported, trusted and given the space to redesign how care is delivered in service of better outcomes for patients and communities. That is how the NHS can continue to meet the needs of the communities it serves.
Huw Thomas talks about this and more in the Unlocking Wales' Productivity Potential podcast episode Productivity in the Public Sector. Listen to the podcast here.
