Profile: Professor Dame Carol Propper on the NHS in crisis

Professor Dame Carol Propper tells us about her research into the UK’s nursing problem and explores some of the issues plaguing the NHS

Universal, equitable, comprehensive, high quality, free at the point of delivery and centrally funded – these were the founding principles of the UK’s National Health Service (NHS) when it was created in 1948. But today the institution, besieged by financial woes, is facing yet another series of crises, as well as growing public outcry over the quality of its services.

Dame Carol Propper is Professor of Economics at Imperial College Business School, a research associate at the Institute for Fiscal Studies and member of the Prime Minister’s Council for Science and Technology. Using the NHS as her “laboratory”, former president of the Royal Economic Society Professor Propper has focused her research on the impact of competition in healthcare, the impact of incentives on the quality of healthcare delivery and health system productivity, and the interaction between the state and private markets. She was also a member of French President Emmanuel Macron’s expert commission to investigate three of the biggest long-term challenges facing the world’s economies: inequality, climate change and demography, including the problems associated with an ageing population.

Solving the nursing problem

After years of researching choice and competition in the healthcare sector, more recently Professor Propper has been focusing on the “nuts and bolts of the production of healthcare”. Using her access to NHS data, she is working with several experts, including colleagues at the Institute for Fiscal Studies, to research nursing teams.

“The NHS went into the pandemic already short of about 50,000 nurses and, with global competition, it’s important to solve this shortage and keep nurses in post,” she says.

Her particular focus has been on which type of nurses within a nursing team really matter when it comes to patient outcomes.

“We’re looking at a very extreme situation – whether a patient has died – and we’re asking if it matters if you’re missing a nurse. And, if so, does it matter if you’re missing a senior nurse, a qualified nurse, an agency nurse or a healthcare assistant.”

The NHS has been through many crises since 1948 and each time we’ve successfully managed them

Among their findings so far, they have discovered the most important nurses in the prevention of patient deaths are the senior ones.

“The policy implication of this is that you shouldn’t keep trying to fill vacant nursing posts by substituting them for less qualified people. Secondly, you should be trying to retain the nurses you already have because there’s a clear return to both seniority and familiarity with the hospital.”

Alongside this, she is working with academics Dr Andre Veiga and Dr Stephan Seiler in the Business School’s Marketing Department to find out what nurses value in their work other than pay. With a regulated pay scale in place, jobs don’t really differ according to salary, so the team are looking into how hospitals can boost staff retention without using higher pay as an incentive.

Rise in private healthcare

When it comes to the NHS in the post-COVID landscape, Professor Propper highlights the fact the institution is “facing a lot of different pressures at the same time – all of which demand more money”.

“We’ve seen senior staff choosing to take early retirement, the doctors' pension furore, which some have argued is causing people to leave the NHS prematurely, and the GP shortage, meaning lots of people are unable to get appointments. The huge rise in energy prices is also putting further pressures on NHS budgets.”

Additionally, the increase in waiting times has led to a huge shift in the number of people opting to use private healthcare. Earlier this year, The BMJ revealed more UK adults have been seeking private healthcare due to the poor access to care exacerbated by the pandemic, warning this threatened to create “a two-tier system”.

The NHS went into the pandemic already short of about 50,000 nurses

This is something Professor Propper had predicted: “Whenever there’s a crisis in the NHS, waiting lists rise, and when that happens the demand for private healthcare rises.”

The current situation, she believes, is likely to lead to a review of how the NHS is financed, looking into European healthcare models based on social insurance.

“Social insurance is not very different from tax financing because, where these systems exist in Europe, individuals with lower incomes tend not to have to pay anything while individuals who are higher income generally share the insurance costs with the state.”

With so many problems plaguing the NHS at once, some have dubbed this a “make or break” moment for UK healthcare but Professor Propper isn’t convinced.

“The NHS has been through many crises since 1948 and each time we’ve successfully managed them – and that’s with one of the lowest levels of funding of any wealthy European country.”