Admin matters: the impact of NHS administration on patient care

It is hard to imagine how the NHS would function without its administration (admin) processes. These processes work – often behind the scenes – to make sure patients, staff, information and equipment are all in the right time and place to ensure high-quality health care. Here, we focus on one aspect of NHS admin that is often overlooked: the patient perspective. We explore what happens when you view NHS admin through the eyes of a patient (see box below).

More than one million people use NHS services every day. Many will have one or more long-term conditions and will access care from different teams, often in different locations and sometimes from different organisations. However, people’s experiences of interacting with NHS admin processes have not received much attention. While there are forums where people comment about NHS admin, research on the topic has more often focused on how admin can affect staff, organisational efficiency or patient safety (eg, Schwarz et al 2019; Burnett et al 2011; Sanjay et al 2007). Emerging research suggests that admin plays an important role in shaping patients’ experience of care. Recent analysis of the English Cancer Patient Experience Survey revealed that the co-ordination and administration of care were the strongest predictors of patient satisfaction with cancer care, across a diverse range of patient groups and treatment pathways.

As patients are increasingly accessing health care digitally and with further integration of health and social care, this is a good time to explore the role admin plays in care quality.

Here we consider two key questions.

1. What do patients and carers say about their experiences of NHS admin and its impact on them?
2. How could patient and staff user insights be used to improve NHS admin for patients?

We draw on work conducted by The King’s Fund; Healthwatch England, the independent champion for users of health and care services; and National Voices, a coalition of health and care charities. (For details of how we conducted the work for this project see Appendix A). National Voices has published its analysis of patients’ experiences of admin. The King’s Fund also interviewed ten staff working in secondary and primary care.

Patients and NHS staff are affected by admin processes on a daily basis – and patients often turn to staff for help when they encounter problems with accessing and navigating care. We looked at both patient and staff perspectives on what it is like to use NHS admin, to understand the impact it can have and where there are opportunities for improvement.

Patients and carers

The King’s Fund, National Voices and Healthwatch England used several approaches to ask people about their experiences of NHS admin (see Appendix A).

• The King’s Fund analysed a sample of 310 patient stories posted on Care Opinion, an online feedback platform.
• A focus group with ten people with hearing impairments, facilitated by National Voices in collaboration with SignHealth, a charity supporting people with hearing loss.
• Interviews with nine people with experience of using multiple health services, eg, because of a long-term health condition, conducted by National Voices.
• Five local Healthwatch in different parts of England engaged people using multiple methods, including face-to-face conversations, telephone interviews and online feedback tools.

The Care Opinion data provided a snapshot of patient experiences of NHS admin. Key findings were as follows.

• Admin processes and/or reception staff were mentioned in 42 per cent of the stories. Of those, there was a mix of positive and negative experiences (and some stories included both positive and negative elements); 52 per cent were negative overall.
• Most comments about admin related to primary care services, and included reports of dissatisfaction with routine processes such as appointment booking. Others described experiences in which admin processes had gone wrong, eg, prescription requests not being processed.
• Admin problems led to a mix of practical consequences – eg, people spending time re-booking appointments cancelled at short notice – and emotional impacts, such as stress and frustration.

Subsequently, our work with National Voices and Healthwatch England allowed us to explore these experiences in more depth. We found that that admin can have an impact on people in a number of ways. Not only is admin an important factor in how people access care, but it can also influence how they feel about their care and even affect care outcomes. People described a range of experiences – some positive, many not. Below, we consider five interlinked categories that illustrate the range of impact admin experiences can have on patients: patient safety and clinical outcomes; time and money; emotional wellbeing; trust and satisfaction with the health service; and their understanding of, and involvement in, health care.  

Patient safety and clinical outcomes 

A small number of people related experiences in which they felt admin errors or shortcomings had had significant consequences for their health outcomes. Examples included medication errors or being unable to access prescription medication from a community pharmacy because of a communication problem. Research highlights that admin errors have been connected to readmission to hospital, medication errors and serious harm.

Time and money

Patients described how poor communication meant they wasted time and energy navigating health services, and how they had sometimes incurred financial loss (for travel or through loss of salary) that they could have avoided if communication had been better. For example, we heard about people spending time travelling to appointments, sometimes taking time off work or securing cover for caring commitments, only to discover consultations had been cancelled or delayed at short notice.

Other people mentioned that phone calls went unanswered when they called to book or rearrange appointments, and they wasted time trying to get through multiple times. Other research has also noted patient complaints over phone calls going unanswered, phone lines being engaged and the financial cost of making multiple calls to chase up appointments. People with additional needs experienced other challenges in navigating the system and felt their ability to access care was hindered when, for example, admin breakdowns meant British Sign Language interpreters were not available and consultations had to be rearranged.

Both patients and staff acknowledged that some of these issues may be due to a lack of capacity and demand pressures that meant clinics were cancelled at short notice for example. While some patients expressed sympathy with staff working under real pressure, they also felt issues were sometimes exacerbated by poor admin processes that affected their care and wasted their time.

Emotional wellbeing

Patients revealed the emotional impact of admin processes that are not intuitive to use. They spoke of feeling frustrated, exasperated, stressed and anxious when trying to get appointments, at a time when they could already be experiencing some distress from health problems. Some also expressed fears about missing appointments due to poor-quality communications, for example, receiving an appointment for a date that had already passed, and finding it difficult to secure a new appointment.

Other patients spoke about how they found NHS communications inflexible and often one-way, with no options for people to respond or for accommodating specific needs.

Some patients felt that automated warnings about costs of missed appointments lacked empathy. People with additional needs spoke of admin systems that did not meet their needs and said stress was a common feature of their interactions with the health service.

As a result of admin failures, some patients and carers felt they had to ensure the system worked by checking admin processes themselves. For example, some patients felt they needed to prepare questions about previous tests, or chase progress of any next steps for care after a consultation to be confident that actions took place.

Trust and satisfaction with the health service

Poor admin can change how people feel about health services, which has implications for how they interact with the NHS, leading to delays in treatment and, potentially having an impact on their health outcomes. Some patients felt dissatisfied with the processes of getting appointments, attending appointments, and receiving follow-up communications – such as discharge letters. In some cases, these experiences undermined people’s confidence in the quality – including the clinical quality – of services.

Some patients responded to these issues by changing how they access care, for example, by seeking care from another GP or hospital or from A&E. Others described how their exasperation meant they had reached a point where they chose to rely on care from family or friends or manage their health independently. Some believed that this had contributed to their health deteriorating.

Understanding of, and involvement in, health care

People described sometimes being confused by communications, including receiving multiple communications that contradicted each other (for example, a hospital sending a series of letters scheduling and cancelling appointments) resulting in missed appointments. Research has also suggested that poor-quality referral letters were linked to patients missing appointments. For those with additional needs, these challenges are compounded because standard communications can be inaccessible. People felt more isolated when they were unable to speak to a professional who could provide clarification.

Some patients reflected that NHS communications can create a power imbalance between services and patients because patients might find it difficult to understand their care. Some people described feeling disempowered.

For some, the cumulative effect of communications that do not meet patients’ needs contributed them perceiving their overall experience of care as lacking dignity and respect.

Staff

The King’s Fund interviewed ten members of NHS staff working in primary and secondary care services in a range of operational and strategic roles. Their reflections on their experiences of admin illustrate two overarching points. First, staff recognise that, despite their best efforts, admin is often sub-par and negatively affects patients’ experience of care. Second, steps to improve admin for patients could also help staff to use their time more productively and improve their working lives.

Much like patients, staff want robust admin processes that are intuitive to navigate, empower patients and work for all patients. They recognise this as a key aspect of good-quality care. Staff highlighted a number of areas that need to be addressed. 

• Contact information for patients: some staff said that sometimes providers do not have up-to-date contact information, or are not aware of patients’ preferred communication channels, hampering efforts to communicate effectively. 
• Changing patient need: staff explained that admin is often designed to provide information to patients who are undergoing a single episode of care. Problems also often arise for patients managing one or more long-term conditions and/or who have additional needs, such as a disability. Information and communication systems are often not well suited to integrating multiple strands of information.
• Co-ordination between services and organisations. People living with one or more long-term conditions often interact with multiple services or organisations (sometimes over extended periods of time). Staff explained that services and organisations often don’t co-ordinate communications, which means patients can be managing a number of different communications from different sources, which can be confusing.
• Investment in admin. Staff commented that it can be difficult to improve admin systems because spending on them is framed as a cost, and investment faces competing claims from other priorities, eg, possible new clinical services, equipment or estates (particularly at a time when capital funds are limited). Some staff described admin as a ‘Cinderella’ area that deserved to receive more attention.
• Priorities among senior leaders. Senior NHS leaders are managing a range of priorities and staff felt that operational pressures are more likely to command their attention and resource. This can make it difficult to prioritise resources to improve admin processes.

This five-part framework for improving NHS admin (see Figure 1 below) is based on insight from patients and NHS staff. The framework suggests how patient-facing admin could improve patients’ experiences of care and contribute to the delivery of the best possible health care.

The breadth of issues raised by patients and staff points to the need to think holistically about admin and the contribution it makes to people’s care. The framework does not offer specific solutions to admin shortcomings. It is intended as a starting point for approaching these issues which is grounded in users’ perspectives. It aims to support services in working in partnership with users to co-design local improvement work. Below, for each domain, we look at how patients and staff articulated the issues, what improvement would look like, and why each domain matters.

Figure 1: Framework for improving patient-facing admin

Admin is co-designed by patients and staff

Issues identified by staff and patients

• It is clear, from both patient and staff perspectives, that NHS admin often does not meet users’ needs. Many factors contribute to this, but the experiences and needs of patients (and staff) are not consistently embedded into the design of admin processes.

How could this be done better?  

• Co-design involving service users is key to developing better admin processes. The NHS can use learning from the service industry sector (Nielsen 2020) to inform work to improve services through in-depth service-user involvement.

Why is it important?

• This shift of perspective – taking a user-eye view and co-designing processes and ways of working – could unlock real change for patients and staff. We think many of the changes outlined below stem from, and are supported by, embracing a user perspective.

Admin that promotes two-way interactions between the service and patients

Issues identified by patients and staff

• Communications from the NHS are often one-way, use only one communication channel (eg, letters), and are sometimes confusing, incorrect or contradict other information patients have received.
• When patients have questions or concerns, it can be difficult to speak to a member of staff.

How could this be done better?  

• Using admin systems that allow services to communicate with patients using different channels – phone, email, letter and possibly others – based on users’ preferences. Patients could then respond to communications using the same systems.
• Ensuring that patients are able to access information and support when they have concerns about their care pathway or a communication.

Why is it important?

• Some negative experiences patients described stemmed, in part, from a sense that communications from NHS services are characterised by a one-size-fits-all approach, with patients framed as passive recipients of communications. Developing capabilities to tailor communication to users’ needs, and allow two-way flows of information, could support patients to feel more engaged and empowered – and reduce the time patients spend trying to find out about their care.

Admin that promotes understanding and confidence

Issues identified by patients and staff

• Patients sometimes find communications difficult to understand, or have questions because of technical language or because communications do not make it easy for them to understand their pathway of care.
• A lack of communication, eg, about what has happened to a referral or about the results of tests, can leave patients feeling confused and unsure about their care.

How could this be done better?

• Ensuring all communications are accessible and easy to understand – both in terms of simplicity of language and how information is presented.
• Providing clear information about the pathway of care patients are likely to follow, the next steps they can expect.
• Acknowledging communications, eg, voicemail messages, from patients and explaining any resulting actions or progress.

Why is it important?

• These improvements could support some patients to take an increasingly active role in managing their health and care. Patient activation has been shown to be associated with improved clinical outcomes and patient experience. For patients with lower levels of activation, better communication could help them feel less overwhelmed by making it simpler to understand the health and care system and what their care may entail.  

Admin that promotes equal access

Issues identified by patients and staff

• For many patients access to care is intricately bound up with admin processes. Processes that are not intuitive can be barriers to accessing care.
• People who have additional needs – eg, people who have hearing or sight impairment, or have a learning disability – can find it particularly challenging to understand their care because communications are not accessible.
• Some digital platforms that are intended to improve patients’ experiences are not designed for users with a range of needs and digital skills. This can be an additional barrier to accessing care.

How could this be done better?  

• Designing communications that are inclusive for people with a range of preferences, and those who have additional needs.
• The Accessible Information Standard provides guidance around how information should be conveyed to patients with particular needs. Meeting these expectations should be the minimum expected from an organisation.

Why is it important?

• Addressing inequalities is a key strategic objective for the health and care system (given greater urgency by the different impact of Covid-19 on different groups). Admin processes that are unable to differentiate and respond to patients’ varied needs create barriers to accessing and using health care services. 

Admin that seeks user feedback and uses it to develop

Issues identified by patients and staff

• Some patients have poor experiences of NHS admin, but these experiences are not routinely captured and communicated to staff and service leaders.
• Some people proactively raise issues via informal interactions with staff, lodging a complaint or offering feedback on platforms like Care Opinion. This insight has real value, but the voices of many patient with relevant experiences are unheard or undocumented.

 How could this be done better?   

• Embedding feedback mechanisms into organisations’ ways of working and harnessing that feedback could drive improvement across organisations – and potentially across health and care organisations working together across a local area.
• Ensuring feedback mechanisms are in place to invite patients’ reflections, including those about experiences of non-clinical aspects of care such as admin. Using the insight generated as a prompt for reflection for services and senior leaders.
• Exploring the experiences of staff who interact with, or are responsible for, admin and feeding this back to senior leaders. Supporting staff to value feedback and engage with improvement informed by patients’ experiences.
• Designing feedback mechanisms to offer insight into how experience varies across services users, with a focus on understanding groups that use health services regularly and have additional needs.

Why is it important?

• The scope to mobilise change is currently hampered, in part, by limited insight into patients’ and staff experiences of admin, including how experience varies across groups. Consistently gathering meaningful insight could help better understanding of the quality of patients’ experiences and make the case for improvement. Additionally, inviting feedback can contribute to empowering patients and staff and harnessing their ideas for improvement.

The patient and staff insight shared here begins to uncover the significant role admin plays in defining people’s experience of NHS care. There are more questions to be explored. But based on the insight gathered for this project, we draw three conclusions.

• High-quality admin has the potential to improve patient experience, promote better care – and contribute to a better working environment for staff. Embracing a user perspective and co-designing ways of working with patients and staff could help to achieve this. We hope our framework provides a starting point for this work that can be adapted by organisations for local development work. It is worth emphasising the contribution admin makes to high-quality care given the numerous other priorities vying for leaders’ attention and resources, and the tendency – in some quarters – to imprecisely equate non-medical expenditure with bureaucracy.
• Improving admin could promote inclusion and contribute to addressing inequalities. The impacts of poor admin are not evenly distributed: a heavier burden is likely to fall on certain groups, eg, people who have long-term health conditions, use several services or have additional needs. Evidence from other settings highlights the unequal impact that admin barriers can have on how people use public services. Given this, truly integrated care will require admin systems that patients – especially those using multiple services – find user friendly and easy to navigate. As integrated care systems embed more co-ordinated care, they have a role to play, working alongside provider organisations, in driving improvements in admin.
• Given the impact it can have, there is a case for better insight into how patients and staff experience NHS admin. Our work offers a window into people’s experiences, but the lack of routine data collection – with some exceptions like the Cancer Patient Experience Survey – leaves open questions about the scale of admin shortcomings, variations across patient groups, and how experience is changing over time. Integrated care systems, and multi-agency partnerships working at place, are well situated to embed insight-gathering mechanisms locally, and arm’s-length bodies have an opportunity to improve understanding of how admin is affecting people’s care, drawing on a range of insight tools including national patient surveys.

The strategic direction of health and care in England will raise new questions about how admin systems need to work. Addressing the legacy of Covid-19 on population health, harnessing the opportunities of technology to support new care models, and more fully integrating health and care services will all place a premium on robust, user-friendly admin systems. High-quality NHS admin will not be sufficient on its own to meet these challenges, but it will be a necessary component.