Wednesday, January 14, 2015

The 90:10 syndrome in the NHS

The National Health Service is a classic example of the 90:10 syndrome. This holds that any activity works satisfactorily, or well, for 90% of the time but very badly for 10%. As I get older I need healthcare more often than I did when I was younger and fitter. In the past few years I have had treatment via my GP, as a hospital outpatient (and once as an inpatient) and once as an emergency A&E case. All of this fell comfortably within the 90% - good treatment and care from skilled and caring people. No complaints.

So when we look at the current problems in A&E or at some GP's surgeries we can be sure that the 90:10 rules are applying. The vast majority of these services continue to be satisfactory. This is not a cause for complacency but the truth is that failure grabs more headlines than competence. 

The NHS is a public service. If it was a private enterprise hard-headed businessmen would decide that the costs of resourcing-up to provide 100% good service at all times were prohibitive. So they either wouldn't do it, or they would charge a premium at certain times. Or they might charge extra for you to jump the queue - like Ryanair does for boarding an aircraft. 

The challenge for the NHS is to get the right cost/benefit mix. And to get public buy-in to standards. To get an instant appointment with a GP or immediate treatment at A&E would be possible, but prohibitively expensive. So first you agree the standard and only then do you resource to that level. Then you monitor performance against the targets you've set. Inevitably at times there will be stresses and this is when you need some built in flexibility. Businesses often cover this by hiring-in extra people when they need them - when demand in the short term exceeds the core supply they have. This is standard practice - and is also a perfectly reasonable procedure for a public service. 

Covering demand peaks with short-term hire is expensive, but not as expensive as resourcing to peak levels and then having employees idle for much of the time. It requires, however, an acceptable that it is desirable that there is a public/private mix in the NHS. This is because it is likely that most short-term hires would be from private sector providers. Once that is accepted it would be reasonable to apply the same principle across the Health Service. Most core medical care activities would continue to be provided by  public sector employees, but some less core or demand peak activities would be contracted-out. I see no objection to this if we start from the premise that we will only be able to continue to afford free at point of use healthcare in Britain, with an aging population, if it as efficient as we can make it. 


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