What are we optimising for? A critique of productivity in mental health services

Across the NHS, and certainly within the Trust I work in, there’s a growing emphasis on increasing productivity, improving efficiency and reducing lengths of stay. These priorities make sense. Resources are stretched. Demand is high. Waiting lists are long. If we can improve throughput where more patients are seen with quicker discharges, we might serve more people with the same or fewer resources.

But I find myself returning to a question that Philip Boxer, an experienced organisational consultant and researcher, posed in a recent talk during the 2025 ISPSO Annual Meeting in Philadelphia: what are we optimising for? And more importantly, who gets to decide?

Boxer’s talk explored how social systems respond, or fail to respond, to the singular, complex needs of individuals. His starting point is simple: the world is turbulent. People’s lives don’t fit neatly into predefined pathways or categories. Especially in mental health, needs are often layered and shaped by trauma, identity, power and history. No two patients present in exactly the same way. Yet our systems are often set up to treat them as though they do.

We’re good at designing services that deliver repeatable outputs: clinical interventions, therapy sessions and crisis responses. These can be scaled, measured, and compared. But when the goal becomes efficiency rather than effectiveness in the context of people’s lives, we risk treating variability amongst users as an anomaly rather than information.

In this light, the focus on reducing length of stay or increasing staff productivity begins to feel less like progress and more like a strategy ceiling: a term Boxer uses to describe the unspoken assumptions that constrain what an organisation believes it exists to do. We say we’re here to support recovery and improve mental health outcomes. But the performance frameworks that dominate organisational life often reflect a narrower ambition: process patients quickly, reduce waiting times and demonstrate value for money.

It’s not that these goals are unimportant. But they risk becoming (false) proxies for care. We count discharges not stability. We measure sessions delivered not relationships developed. And we rarely pause to ask whether we’re making a meaningful difference to the patient’s world or simply managing them out of ours.

Boxer also talks about the last mile problem: the gap between what services offer and what is actually received by the people who use them. In a turbulent world, it’s not enough to deliver services efficiently. We need to ensure they are aligned with the particular configurations of need that individuals bring. This requires what Boxer calls tripartite leadership: the capacity to hold the tension between the vertical (what the organisation is set up to do), the horizontal (what is needed in specific contexts), and the dynamic work of rebalancing between the two.

In practice, that might mean accepting that recovery isn’t linear: someone’s third admission isn’t a failure but part of their journey; continuity of care matters more than standardisation; and that staff need spaces to think, reflect and adapt not just keep up with ever-tightening metrics.

Boxer proposes an interesting alternative. He points to the potential of digital platform architectures to support greater coherence between services and individual needs. But the ideas isn’t limited to technology. It’s about designing systems that start with the user, that treat individuals as agents with knowledge about their own lives, rather than passive recipients of care. It means redesigning systems that allow for choice, co-production and iteration and resist the temptation to simplify what is, by its nature, highly complex.

This has direct implications for mental health services. It means investing in case formulation and relational practice. It means resisting pressures to reduce everything to throughput. It means being wary of models that prioritise what’s easy to measure over what really matters. It means a greater focus on multi-stakeholder engagement. And it means holding on to the moral and psychological dimensions of our work, even when these can’t be captured on a dashboard.

None of this is easy. But what’s the alternative? A system that is efficient but misaligned, productive but ineffective is already playing out. We see it in staff burnout, increasing cases of moral injury, service user frustration and outcomes that plateau despite ever more activity.

So we might ask again: what are we optimising for? Are we designing systems that help people build lives that fulfilling? Or are we optimising the system itself, maintaining flow, reducing friction and merely keeping the machine turning over? If we’re serious about doing justice to those we serve, the answer cannot be productivity and efficiency alone.