Intended for healthcare professionals

Opinion Critical Thinking

Matt Morgan: The NHS needs to be less efficient

BMJ 2023; 383 doi: (Published 21 November 2023) Cite this as: BMJ 2023;383:p2635
  1. Matt Morgan, consultant in intensive care medicine
  1. Cardiff, UK
  1. mmorgan{at}
    Follow Matt on Twitter: @dr_mattmorgan

When I recently returned to the NHS after working in Australia for a time, I was dreading the process of endless applications for usernames, parking passes, and identification badges that lay ahead of me. Luckily, thanks to the NHS’s bureaucratic inefficiency, my existing usernames remained active, the car park barrier opened as before, and my ID badge still worked. Inefficiency worked well.

Now that healthcare budgets in the NHS are glowing bright red, I imagine we’ll soon be hit by predictable plans to try to be more efficient by shaving decimal points off stationery budgets, outpatient clinics, and the free teabag policy. But we should remember the risk of suboptimisation—where individual process improvements end up being to the detriment of the overall organisation.

Some of the most important parts of my day when working in the intensive care unit are the “in-betweens.” These are the gaps between here and there: the wait for the lift to arrive after seeing a patient in the emergency department; the walk with colleagues to buy some lunch; the time waiting for a scan report to be finalised. Although cutting out such “inefficiencies” might seem like a great idea, something less easily quantifiable would be lost.

Waiting for those lift doors to open gives me some time to think about how to manage the patients with more complex problems. The walk to the coffee shop with a colleague is when shifts are discussed and swapped. And the time spent waiting for a scan report gives me a minute to prepare the warning shot I’ll be giving to family members before the scan shows the news no one wanted.

In a system that the King’s Fund think tank has found to be already very efficient in many areas,1 if we resort to salami slicing to make a spreadsheet turn green it can have unintended consequences. A systemwide approach is needed, and we should recognise and be mindful that providing high quality healthcare needs to afford space to the human beings delivering it. Efficiency isn’t everything.


  • Competing interests: I have read and understood BMJ policy and declare that I have no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Matt Morgan is an adjunct clinical professor at Curtin University, Australia, an honorary senior research fellow at Cardiff University, UK, consultant in intensive care medicine in Cardiff, and an editor of BMJ OnExamination.