Lost in the system: the need for better admin

Most people can agree that how the NHS communicates with people around appointments and ongoing care – whether it is by phone, post, text, app or in person – needs fixing.

Getting the basics of admin right – enabling people to book, change or cancel an appointment, and communicating with people about their care in ways that work for them – matters when it comes to people’s experience of using the NHS and judging how well it is working. Even the Prime Minister signalled the problem of poor admin in a speech on the NHS: ‘I am not prepared to see even more of your money spent… on appointment letters, which arrive after the appointment.’

New polling conducted for this long read reveals that 1 in 5 people who used the NHS in the past 12 months received an appointment invitation after the date of the appointment. This day-to-day dysfunction in how the NHS communicates with people has a negative impact on people’s experience of using the NHS and is driving perceptions of an organisation that is wasting money, time and staff resources.

The new government is under pressure from the public to deliver rapid improvements to the NHS. Public satisfaction with the NHS is at an all-time low. In 2023, less than a quarter (24%) of the public were ‘very’ or ‘quite’ satisfied with the NHS. There are many factors that affect this, including what is being reported in the media, political support, and what people are hearing from friends and family who work in the NHS. But one of the key drivers when it comes to overall satisfaction is either their own experience of care or the experience of someone they know.

As well as improving access, safety and health outcomes, ministers know they must also improve people’s experience of the NHS. Helpfully, improvements in admin can be felt more quickly by patients than reform in other areas. Although improvements will need to be delivered by local NHS services, the impetus, energy and focus can come from central government by drawing attention to an area often neglected. The upcoming 10 Year Health Plan is a rare opportunity to signal the importance of admin and set out a plan for improvement.

In this long read, we reveal the scale of the problem, alongside the personal impact of poor experiences of admin. We review what the evidence tells us about patient experience of admin, including findings from newly commissioned polling undertaken by Ipsos on public views and experiences of NHS communications. We offer an explanation for why admin, something so essential to the delivery of high-quality care, has been overlooked and set out six steps for action.

The pivotal but undervalued role of good admin

The story above is not unusual. Over the past few years, the NHS has increasingly been getting the basics wrong when it comes to communicating with patients. We know that too many people struggle to book an appointment, change an appointment or get their test results.

Poor administration is not just an inconvenience. Organisations such as Healthwatch England and National Voices hear story after story about the burden a failing admin system has on patients and their carers. Poor admin can restrict access to the care that people need, negatively affect their wellbeing and have knock-on consequences for staff. If getting into the service has been far more of a challenge than it should have been then the subsequent interactions between staff and patients are already starting off on the wrong foot. And the problems are exacerbated when you have a disability or long-term condition.

In 2021, The King’s Fund, in collaboration with Healthwatch England and National Voices, published Admin matters. It represents one of the few publications to focus on the role admin plays in patient experience. We argued that high-quality admin has the potential to improve patient experience, reduce health inequalities and promote better care. It can also contribute to a better working environment for staff who do not have to treat patients already frustrated and anxious by the process of getting in to see them.

Since we published that long read, all three organisations have continued their work to raise awareness of this issue and to understand what can be done to address it. But three years on, have things improved?

NHS admin continues to be a major issue for people

Patient experience of admin has remained in the shadows, but it is clearly getting worse and needs urgent attention. Efforts to reform the NHS will fail without better admin.

The scale of poor admin

In 2023, Demos carried out polling with the public for their report, I love the NHS but.... It found that, overall, half of the public had experienced a poor communication issue in the previous five years. The report states:

Over and over again we heard stories from patients and staff of critical appointments missed, diagnoses not shared or shared too late, and referrals for treatment that simply went missing.
Demos 2023

This work revealed just how many people have had problems with some of the most basic aspects of how the NHS communicates with them. The polling highlights a frustration which comes through regularly in feedback to Healthwatch England about the lack of two-way communication between the NHS and patients, and the problem people have in responding to messages and information they receive from the NHS – for example, about appointments and test results.

It is too easy to think that admin is just a small part of someone’s overall experience but analysis from the Cancer Patient Experience Survey demonstrates how fundamental this issue is. The analysis of the survey, which looked at what the most important factors are for a good patient experience, found that the number one driver was good administration of a patient’s care (including receiving letters at the right time, doctors having the correct notes/test results, etc).

The burden of poor admin does not fall equally

Poor admin places a particularly heavy burden on people who have additional needs – for example, people who have a hearing or sight impairment, a learning disability, or those with long-term conditions. It is also harder to navigate a complex health system if you have low literacy levels or do not have easy and affordable access to a phone or the internet.

People with multiple long-term conditions are another group who have to take on the burden of admin not being well designed for them. Take cancer for example – over 70% of people living with cancer have one or more serious health conditions. Managing the admin associated with arranging appointments and tests and moving between hospital and the community, or between different clinical teams, can feel like a full-time job to manage. People who use different services can also feel frustrated by having to repeat their communication preferences over and over again.

A driver of complaints

Recent data on NHS complaints shows that not only has the number of complaints increased but that the largest proportion of new complaints made about hospital and community health services by individual subject area was communications, making up 17% of complaints. When you look at the breakdown of what people were making complaints about, many aspects relate to the administration of care, including a breakdown in communication around appointments and delays in getting information and test results. Another area for complaints was appointments themselves, with themes including cancellations, letters not received and failure to provide follow-up.

Much like patients, staff want robust admin processes that are intuitive to navigate, empower patients and work for everyone. They recognise this as a key aspect of good-quality care. When admin is under-resourced and poorly designed, admin staff frequently bear the brunt of patient frustration and anger – for example, when faced with incorrect information, not knowing who to contact and test results that have gone astray.

The consequences for services

Admin doesn’t just affect patient experience, it also has an impact on efficiency and productivity. For example, millions of appointments are missed every year at a huge cost to both individuals waiting for care and the NHS. There are many reasons why people do not attend a scheduled appointment, including difficulty arranging care or transport issues, but poor admin remains a key factor. People are frequently unaware an appointment has been made for them, given the wrong appointment time or unable to rebook an appointment they know they cannot attend.

Our new research shows admin needs urgent attention

Patients need and expect the NHS to communicate better. The existing data shows that patients are struggling to navigate and access the NHS, and this shapes their perceptions of waste, quality and productivity.

To get an up-to-date picture of NHS admin, we commissioned Ipsos to carry out polling¹ with the public and users of services to better understand attitudes and experiences of NHS admin and related communications. Our survey adds to the growing evidence that shows how damaging poor admin can be.

Overall attitudes to NHS admin and communication with patients

When asked whether the NHS is good at communicating with patients about things such as appointments and test results, just over half (52%) said that the NHS was good, while 1 in 4 (25%) said it was poor. Over 2 in 5 (42%) said the NHS is good at keeping people informed about what is happening with their care and treatment, such as referrals and waiting times, while approximately 1 in 3 people (32%) said it was poor. Over 2 in 5 people (43%) said the NHS is good at ensuring there is someone for patients to contact about their ongoing care if they need to, while just less than 1 in 3 people (28%) said it was poor.

When you look at the results by demographic group, a clear picture emerges in which some groups are more disadvantaged by poor admin than others.

People with a long-term health condition are more likely to say the NHS is poor at keeping people informed about what is happening with their care and treatment, such as referrals and waiting times (38%, compared with 29% of people who do not have a long-term condition) and ensuring there is someone for patients to contact about their ongoing care if they need to (32% compared with 25% of people who do not have a long-term condition).

Across all three questions, people who say they are struggling financially are more likely to say the NHS is poor in all three areas: communicating with patients about things such as appointments and test results (36%, compared with 22% of those who say they are very or quite comfortable); keeping people informed about what is happening with their care and treatment (47% compared with 29%); and ensuring there is someone for patients to contact about their ongoing care if they need to (40% compared with 25%).

Experience of specific NHS admin and patient communication issues

We asked whether people had used a range of NHS services in the previous 12 months, either for themselves or someone they care for. Those who said yes were then asked whether they had experienced any of the specific issues listed below. These issues were based on those that regularly feature in the public feedback gathered by Healthwatch England.

Nearly 2 in 3 (64%) of those who had used at least one NHS service in the previous 12 months had experienced at least one of the admin issues asked about (either personally or it had happened to someone they care for). Almost 1 in 3 people had personally had to chase for results (32%), while 1 in 5 (20%) had received an invitation to an appointment by letter or text after the date of the appointment.

The data shows that some groups are more likely to have experienced these issues than others. Those from ethnic minority backgrounds, those with long-term conditions, and those who say they are struggling financially are all more likely to have experienced these issues. The chart above clearly shows the disproportionate impact poor admin is having on carers. Across all the examples asked about, carers were more likely to report that these issues had happened to the person they care for.

The impact of poor admin on public perceptions of the NHS

When we asked all those who had experienced a problem with NHS admin what impact this had on their perceptions of the NHS the top three answers given related to waste.

• Over 3 in 5 people (61%) said it made them think NHS money was being wasted.

• More than half felt that their time was being wasted (56%).

• More than half felt that staff time was being wasted (55%).

  

However, poor admin also has consequences for perceptions of care, with nearly half of people (47%) saying their experience(s) made them think the quality of care the NHS provides is poor. There is also an effect on people’s willingness to seek care, with over 2 in 5 people (45%) saying their experience made them give up seeking care or treatment on that occasion and a similar proportion (42%) saying it made them less likely to seek care in the future. These are worrying findings, with potentially significant consequences not only for individuals’ health, but also in terms of storing up problems for the health and care system over the longer term.

Why does patient experience of admin get overlooked?

Despite growing evidence on its importance for those using services, admin generally is often seen as mundane or boring: a task to be avoided. Too often admin in the NHS is positioned as an area where costs can be saved and red tape cut. It is no surprise then that NHS admin, including the staff who deliver it, rarely receives the attention and priority that it – and patients – deserve.

But it still seems curious that something that everyone acknowledges as an issue and is so central to the delivery of high-quality care continues to be overlooked. When there are improvements, they tend to be a by-product of another initiative, like reducing waiting times or the introduction of a new digital platform, or a support act to ensure the success of new policies or interventions, such as patient-initiated follow up or virtual wards.

We think there are further explanations for why patients’ experience of admin has not been given the same attention as other issues or seen as critical enough to merit a focus in its own right.

• Patient experience of admin is not routinely measured. Most national surveys do not ask patients about their experience of admin, although the Cancer Patient Experience Survey is a notable exception. But admin does show up in complaints missed or late appointments, the cost of staff time in rearranging appointments, staff morale and patient satisfaction. This lack of data means we cannot understand what is working well, what needs improving, or what variation exists between groups. Moreover, it means that targets and goals cannot be set to drive improvement.

• Admin is designed from an organisation’s perspective, not a patient’s. With more than 1.7 million interactions with the public every day across primary, community and secondary services, it is easy to understand why the NHS might organise admin around single conditions, such as diabetes or cancer, or single episodes of care. But we know people struggle to receive co-ordinated care when the admin is managed by different individual NHS organisations, or across a pathway of care. The NHS is not an organisation that prioritises user-led design and poor admin is just another example that reinforces this deficiency.

• Admin is everyone’s business but no-one’s responsibility. Admin is the wiring connecting all parts of the system together to make sure that the right people are in the right place at the right time so that people get the care they need and feel they matter. It’s part of everyone’s role – from operations, estates, digital and communications through to elective recovery, clinical care and human resources. But it is hard to find the person (or team) that is accountable for how patients experience admin and for improving it.

• Patient experience of admin is not seen as an urgent issue. Admin may not make the headlines in the same way as waiting times or cancer targets, but recent research suggests that the public say it is a key concern. When people are given time to think in depth about health and care, they choose to focus on actions that will improve both staff and patient experience. Unsurprisingly, admin emerges as a top priority. Our own polling shows how serious the consequences can be when people’s experience of admin is poor, with over 2 in 5 people saying it has made them less likely to seek care in future.

• Admin is largely delivered by a low-status workforce. The contribution made by admin professionals tends to be overlooked. Their voice is rarely heard and transformation programmes that impact directly on their work are often implemented without their input.

Examples of good admin exist but are hard to find

There is growing interest in how best to deliver admin that works well for everyone – patients and staff. But despite the interest in improving patient experience, there is limited evidence or advice to guide those wanting to make improvements. It doesn’t help that great admin can be hard to spot, unlike poor admin that shows up everywhere (in complaints, missed appointments, lost results and demotivated staff).

We have heard from many organisations that are keen to improve their admin and are trying different approaches to achieve this and looking to learn from other sectors. But it remains early days, and we are yet to learn what works in the long term. In the meantime, existing guidance such as the Accessible Information Standard, communicating with people on the waiting list and the digital design for inclusion standards are all good places to start. And recent work on the use of AI in NHS communications highlights how rapidly radical change might happen.

But if you want to know how to design and deliver great admin, you need to ask your patients and your admin staff. There is no shortcut to asking people about their experiences of booking an appointment – whether it’s online, in person, on the phone or by letter. The framework for improving admin that we set out in Admin matters encourages organisations to seek feedback from patients and staff. We think there is no better place to start.

Where next?

Admin isn’t just about making sure people are in the right place at the right time – admin underpins how people feel about the NHS. From the NHS’s front door to the exit, admin paves the way for people to feel they matter. The public say this is an issue that is important – and clearly in need of improvement.

The government has set out its stall on reforming the NHS and admin is one area where the public could feel improvements within a relatively short timeframe. Getting the basics right when it comes to admin also provides a significant opportunity for government to improve overall public satisfaction with the NHS.

We need to start thinking differently about admin and recognise its value

We are optimistic and see a huge opportunity to improve how people experience the admin that surrounds their health care. Indeed, the government’s reform programme provides a wide-reaching platform for improving admin. The Fuller Review on red tape and the 10 Year Health Plan for the NHS both offer opportunities to design and deliver great admin that can enhance patient experience, improve access to care, tackle health inequalities, reduce waste, increase productivity, and improve the working environment for staff. The emphasis on patient experience in the elective reform plan demonstrates a welcome, renewed focus in this area.

Increasing national (and political) attention on admin is welcome but will need to be matched at a local level. People need to see improvements if they are to feel that the NHS is working better and providing a level of basic service that they now expect to find in any other sector. Great admin requires a focus from all parts of the system, not necessarily huge reform or significant investment. It requires admin to be valued and viewed in new ways that put the patient first.

Priorities for improving admin

1. Put admin on the agenda

The first step to fixing admin has to be raising awareness both of the scale of the problem and the effect it has on patients (and staff). Admin is not an adjunct to high-quality care – it underpins it. In fact, the research clearly shows that great admin sits at the heart of patients’ experience of great care. National and local systems need to show they understand the role admin plays.

How to make it happen:

• The government needs to recognise admin as key to improving patient experience in the 10 Year Health Plan for the NHS.

• Integrated care systems (ICSs) and provider organisations need to report on data annually, showing they understand how people experience admin, and how they are working with people to find solutions.

2. Measure patients’ experience of admin

Exercises like the polling conducted here provide a worrying snapshot into the extent of the problem. The significant amount of feedback that Healthwatch England has received on this issue tells a similar story. We need more data to help quantify the problem, measure improvement and understand variation between groups and areas.

How to make it happen:

• National patient experience surveys need to follow the example of the Cancer Patient Experience Survey and ask people about their experience of admin.

• Locally, ICSs and provider organisations need to collect information about people’s experience of admin through their existing mechanisms for collecting patient feedback.

3. Develop clear goals and targets for local systems

While the ambition for NHS admin should be set nationally, the solutions will need to be developed locally. The improved measurement of patient experience of admin in national patient surveys outlined above will allow tracking and management of these goals and targets.

How to make it happen:

• The Department of Health and Social Care and national bodies need to work with patients and staff to develop a national ambition which describes the change people want to see on NHS admin.

• The government needs to hold systems and organisations to account for their delivery of improved admin against goals and targets.

• Local systems and organisations must work with each other and with patients and staff to develop a local ambition that describes the change people want to see on NHS admin that meets the range of needs of the local communities.

4. Design and deliver two-way communications

Too often admin is designed by the system for the system with little thought given to whether it works for users. In many places, people are treated as passive recipients of care; receiving texts that they can’t respond to or given a telephone number that remains unanswered, or only able to send a message to a service within office hours. A shift to two-way communications, where people can communicate with the NHS in ways that suit them, would help build public confidence and trust in the NHS. It would also support patients to feel able to better manage their own health – and help to address health inequalities.

How to make it happen:

• NHS organisations must work with patients, staff and communities to design and test new approaches to NHS admin.

• NHS providers need to ensure that existing and new digital platforms, including the NHS app, allow for two-way communications and are responsive.

• NHS organisations need to play a role in reviewing local initiatives and sharing the learning on how to work with the public to co-produce, design and evaluate great admin.

5. Reduce the admin burden placed on patients and carers

People’s ability to manage the burden of poor admin is not felt equally. Although frustrating for many, poor admin can also mean that existing health inequalities are exacerbated. The move towards digital, including the NHS app, clearly offers new opportunities to improve how people experience admin – but like in other sectors such as finance and retail, users will inevitably be asked to take on more of the admin themselves. Again, new approaches will need to be designed and tested with patients – and greater attention paid to ensuring that admin, including the use of AI, is inclusive. The overarching principle needs to be that communication is personalised and capable of meeting people’s different needs.

How to make it happen:

• The CQC needs to give specific focus to this in their inspections of providers, ensuring compliance with the current legal requirements set out under the Accessible Information Standard so that people can access the information they are sent about appointments or their care in a format or size they can read.

• NHS organisations must work closely with their patients, staff and the wider community to co-develop solutions that are tailored to different needs and evaluate their effectiveness.

• Local systems and organisations need to work with patients and staff to ensure patients know who to contact and feel that their care is being co-ordinated across the health and care system.

6. Invest in admin staff development

Local systems and organisations should recognise the role admin staff can play in enhancing patient experience and helping to address health inequalities. This includes investing in training and professional development for admin staff and giving them a stronger voice in decisions that affect their work.

How to make it happen:

• NHS England must ensure that admin staff are included in future workforce plans.

• Local organisations and systems need to show they recognise the contribution of the admin workforce and invest in their professional development.

This long read is designed to raise awareness of the importance of patient experience of admin. The polling by Ipsos shows the extent of the problem and how important it is to get the basics right and for admin to be recognised as key to the delivery of a high-quality NHS. We want admin put on the agenda and to be recognised as a key factor in shaping both people’s experience and perceptions of the NHS.

We welcome the increasing attention that admin is starting to receive from the government and the NHS. Too often admin in the NHS is designed by the NHS for the NHS with little thought given to whether it works for patients. This long read shows that you need to put the people who use admin at the centre of how you design, test and deliver it. Great admin has the potential to transform people’s experience of care and ensure that everyone has equal access to it.