A recent HSJ Daily Insight piece by Steve Black posed an uncomfortable question: how much NHS staff time actually contributes to patient outcomes?
The answer, based on time-based analysis from Robert Barker’s book The Time-Based Organisation, is stark. One NHS trust study tracking an outpatient through their treatment found just 14% of activity was “value-added time.” The other 86% was waste. Systemic inefficiency baked into the way pathways operate, not individual failings.
As Black puts it, most NHS activity “sustains queues rather than cures patients.”
1.1 Cancer Pathways and Clinical Stakes
For cancer care, this matters beyond efficiency metrics. Delays in diagnosis and treatment directly worsen patient outcomes. The 62-day and 28-day faster diagnosis standards exist because speed matters. Waits kill.
Map a typical urgent suspected cancer pathway from referral to discharge and you’ll find the same patterns Black describes. Referrals sitting in queues. Appointments scheduled and rescheduled. Results chased manually. Information transferred between systems by hand. Nobody sees the full picture because time bleeds out across dozens of small steps.
1.2 The Buried Report Problem
Black’s article includes a telling anecdote. A manager at one NHS trust completed a detailed time-based analysis, revealing significant waste and improvement potential. When they presented it to the chief executive, the response was: “Bury the report. It’s too revealing.”
This happens more than you’d think. Exposing inefficiency creates political discomfort. It raises questions about why things haven’t been fixed. It can threaten budgets, because if a department proves it can operate more effectively, it risks losing resources.
But the bigger issue, as Black identifies, is capability. When experienced NHS staff were asked why analysis rarely translates into action, the feedback was blunt: “Nobody understands flow.” The NHS lacks operational managers with the skills to turn diagnostic insight into practical change.
So reports get written. Recommendations get filed. Problems remain.
1.3 What We Do Differently
At e18, we’ve spent a decade working with NHS trusts on automation programmes. The lesson we keep learning: process mapping only matters if it leads somewhere.
Our Cancer Pathway Mapping initiative applies the same time-based methodology advocated by Black. Through structured workshops, we map the full patient journey end-to-end, measuring where time is spent and identifying where it is lost. For lung cancer pathways, this means examining each stage of the process—from referral and appointment management to assessment, diagnosis, and tracking, treatment, and discharge.
Equally important, however, is challenging the status quo. During the workshops, we critically evaluate the entire pathway and define the ideal future state to ensure we are not simply automating a broken or suboptimal workflow. We ask fundamental questions: Are there steps that add little or no value and exist only because of technical limitations? Are there steps that should be part of the pathway but are avoided because they require heavy manual effort?
By challenging the current process in this way, we can define what an optimal pathway should look like and identify where the greatest improvements—and the greatest value for patients and clinicians—can be achieved.
All this said, the key difference lies in what happens after the initial challenges have been scoped.
1.4 Time For Action
Each workshop documents the current-state processes, highlighting inefficiencies and limitations. The outcome is a comprehensive report with clear recommendations, proposed solutions, and projected outcomes—something organizations can act on immediately.
The report maps out the improved future-state process identifying where technology can replace manual tasks. In some cases, the right approach is to automate specific bottlenecks within the existing process. When this is the case, we quantify the potential time and cost savings and create a prioritized implementation roadmap. These automation opportunities typically arise with tasks such as generating appointment letters, transferring data between systems, scheduling and rescheduling appointments, sending patient reminders, and ensuring required test results are available ahead of appointments.
In other situations, the analysis shows that the greatest impact (and cost savings) comes from implementing an orchestration layer to the automation that spans the entire process end-to-end. Here, we also provide a clear road map and the required tools for success.
1.5 What does a process look like when it is orchestrated by automation?
Orchestration becomes particularly valuable in long-running and adaptive processes where each case must be tracked throughout its journey. Healthcare pathways are a good example. In cancer care, thousands of patients may follow complex treatment pathways spanning many years, involving multiple steps, changing conditions, and evolving clinical decisions based on diagnostic results.
In these situations, automating individual manual steps within an otherwise fragmented process may deliver limited value. A more effective approach could be to introduce a solution that tracks each patient along their treatment pathway, automates all administrative tasks that do not require human decision-making, and seamlessly integrates human work where clinical expertise is required.
Using this approach, we have automated entire cancer care pathways with excellent results—cutting administrative costs, eliminating backlogs, ensuring timely treatment, and enabling healthcare professionals to spend more time with patients when it matters most. Process orchestration also creates a single transparent view of the entire pathway for clinicians—making all-important tracking and measuring an inherent part of the solution!
Read more about our case examples here.
1.6 The Spreadsheet Instinct
Healthcare’s default response to problems is tracking them. Wait time issue? Create a dashboard. Pathway delay? Build a spreadsheet to monitor it.
Tracking doesn’t solve anything. It just makes problems more visible while staff spend additional hours maintaining the tracking system itself.
The shift we’re seeing across our NHS partners works differently. Instead of monitoring where the waits are, build systems that eliminate them. Automate the referral triage. Remove the manual handoffs that create delays. Take control of the entire workflow and use people effectively where expert time is needed—for the benefit of patients.
Across West Yorkshire, six acute trusts already have mature automation programmes running on standardised infrastructure. The foundation exists to implement pathway improvements at scale.
It is also important to emphasize that implementing these automation solutions does not require heavy, long, and exhausting projects. Solutions can be built within months, with customers involved in a structured and time-efficient way that respects their limited availability.
1.7 What Comes Next
Steve Black’s piece is a diagnosis. The time-based methodology, he champions, is the right approach to understanding where pathways break down.
But diagnosis alone changes nothing. The NHS has enough reports revealing the scale of the problem. What’s missing is the operational capability to act on them.
That’s what we focus on: turning pathway analysis into pathway automation. Designing and delivering solutions based on what best serves patients and clinicians—not constrained by the limitations of existing systems.
Getting Started with Free Support from the e18 Community
The e18 Automation & AI Community is a free, open space for NHS teams to explore what works in practice. Inside, you’ll find real use cases, peer discussions, and practical resources to help you move forward.
More Information
Email: info@e18-consulting.com
[By Louise Wall]
