Rory Sutherland Rory Sutherland

A nice, cuddly NHS would be bad for us

We can have an efficient health service or one no one complains about. We can’t have both

Recently the NHS postponed a large number of non-urgent operations to cope with what is known as the ‘annual winter crisis’. Naturally, this outcome was treated as a scandal in the press, and there were predictable calls for Jeremy Hunt to resign. But the fact that non-urgent operations are postponed is not by definition bad. It might be evidence that the NHS is working well. Or at least that it is doing what it is supposed to do, which is to deploy necessarily finite resources on the basis of patient need, rather than some other criterion — such as profitability or ability to pay. Making people wait for less urgent operations isn’t a bug of the NHS; it’s a feature.

People can and do distinguish between a common-pool resource and a private good, and judge them differently. For instance you won’t often hear me say, ‘Sorry I’m late: some bastard in an ambulance needed to get to a car accident.’ I accept that the road network is a shared resource, and other people may need it more urgently than I do. But the discussion around the NHS, and the metrics by which it is assessed, encourage us to judge a common-pool resource by the same selfish standards we apply to private goods like Domino’s Pizza or M&S. Common-pool goods are different. A single customer can judge whether M&S or Domino’s are doing a good job; a lone patient cannot accurately assess a hospital. The customer is always right; the patient isn’t.

Patient satisfaction is a problematic measure because patients, on average, are more impressed by the feeling that you care than the knowledge that you cure. They judge their experience on almost any measure except objective health outcomes. It is worth remembering that Harold Shipman — not a terribly good GP by most objective standards — was nevertheless revered by his patients, perhaps on account of his willingness, easily explicable in retrospect, to visit them in their own homes.

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