Do missed appointments cost money?

There has been a rash of stories about missed appointments costing vast amounts of money:

• The BBC quoted Epsom and St Helier who estimated that missed appointments cost the Trust £5.6m
• The Sunday Express quoted a figure of £800m lost for the whole of the NHS

The question is: do they cost so much money?

Let us look at how these figures are arrived at.  They are arrived at by multiplying the number of missed appointments (DNAs in the jargon - Did Not Attend) by a notional cost of the missed appointment. And the notional cost in these two articles are c. £120 per appointment.

There are two weaknesses to this methodology.  First, the analysis assumes that a missed appointment means that the whole infrastructure of out-patient care (nurses, receptionists, test facilities, and doctors) are just kept waiting looking at their watch, and wasted.  Second, the analysis assumes that the cost of this is the same as PCTs are charged for each appointment (which is roughly £120 when averaged between new attendance and follow-up tariffs).

The first is a ridiculous assumption.  I know of very few clinics that work on the assumed basis.  In reality, most clinics are overbooked, assuming some DNAs.  Moreover, outpatient clinics are very poorly analysed and planned according to some ancient template.  As a result, patients are allotted times that may bear little relation to reality.  How many times have you gone to see a outpatient waiting area that is rammed full?  How often have you as a patient waited for far too long to see a clinician.  The basic point here is that in reality DNAs are a small wrinkle in our imperfect outpatient demand and capacity management; and only a small fraction of the allotted time is actually wasted if any.

The second assumption is just wrong.  It shows a misunderstanding of cost and price.  If you break a pram in John Lewis, the cost to John Lewis (assuming they do not charge it to you) is not the full price of the pram - but the cost to them (what they will pay to have it replaced).  Similarly the price of outpatient consultations is not the same as their cost.  And the marginal cash cost of a consultation will be much lower than the £120 charged to PCTs.

So these losses are just paper losses.

In reality, DNAs impose large costs when clinics are analysed and managed very well.  But hospitals who manage that will also be managing their DNAs to the minimum unavoidable level.  These bald and high-level estimates are just idiotic, and we could do without them.

Worst 10 Trusts for Management of Access Targets - Disproportionately FTs

It is a well-known secret that targets based on clock-stops promotes inappropriate behaviour.  They motivate Trusts to focus on ensuring that most of the people starting definitive treatment are within 18 weeks, rather than treating patients in referral order (after allowing for clinical urgency).  It is a subtle, but important distinction; and Trusts can get stuck in the trap of managing clock-stops - not their total patient base.

This post names and shames the worst of these Trusts.  And it finds that Foundation Trusts are actually poorer at governing access targets.  So much for the ability of FTs to improve performance and governance.

This inappropriate management does not necessarily happen by strategy.  It can happen by by the natural dynamics of actions in a Trust, without active thought to it.  For example, how many Trusts have breach lists - patients who will breach if not treated imminently?  And how many service managers run around trying to get these patients on a proximate operating list?  The effect of this is not to treat patients in order of referral; but to focus on those patients who are about to breach 18 weeks.  The effect of this is to treat people within 18 weeks disproportionately.

It also happens because of the culture within the system to achieve 18 weeks.  To take this out of context, it is a bit like the treatment of Iraqi prisoners.  The Western Forces had no active strategy to degrade prisoners at Abu Ghraib; but the overall culture and philosophy of the western forces was to demonise and dehumanise the opposition.  In addition, there were subliminal signals from leaders that international humanitarian law was over-zealous.  That slowly results in (to coin a phrase) "institutional torture".  Similary, the culture, targets and performance management within Trusts is on 18 weeks.  Senior management do not focus on the length of the longest waiters (and still waiting), but on the 18 week target - which focuses on those being treated in the month.  The result is "institutional neglect" of long-waiters.

This culture also results in many concrete actions to intensify the problem.  In any management meeting, more time is spent on those specialities and services whose performance is at the threshold - who have marginally breached or a marginal change will lead them to breach.  Central resources, such as analytics, IT, transformation (what is that, by the way?), strategy and - critically - investment, get disproportionately devoted to these areas.  The end result is that those areas with much greater difficulties (e.g., orthopaedics) get ghettoed into the "too difficult" box, and resources are spent negotiating different profiles with commissioners for those.  The overall result is that patients get treated out of referral order (without clinical justification).

So if that is the problem, how do you identify the worst offenders.  This can be done by looking at the discrepancy between the time people being treated have waited, versus the length of time waited by those not being treated.  In general, if you are managing by referral order (disregarding clinical urgency), people being treated should have waited longer than those waiting for treatment.  So if we look at the statistics on referral published by DoH, the percentage of patients treated within 18 weeks should be far lower than the percentage of untreated people within 18 weeks.  So if we are exactly meeting the existing "clock-stop" targets, on average at least 92.5% of all patients (admitted and non-admitted) would have waited less than 18 weeks (this assumes that there are equal admitted and non-admitted pathways - a simplifying assumption).  Therefore, much more than 92.5% of patients waiting for treatment should have waited less than 18 weeks.  But if we find that only 87.5% of patients not yet treated have waited less than 18 weeks, then I conclude that there has been inappropriate management going on.  And I define a new score - which I have called the MM Obstacle Score of -5% (which is 92.5%-87.5%).  In fact, any negative score, and slightly positive scores probably indicates that Trusts are mismanaging access targets.

[I realise that urgency does change this significantly.  I will return to incorporating this factor on a future date. For now, I realise that this is a simplified picture.]

And now to the list of the worst 10 performers.  This is presented at the top of the blog, with their MM Obstacle Scores based on November 2011 statistics.

8 of the worst 10 are actually FTs.  And they are meant to be the ones with a proven ability to govern themselves better.  In fact, if one considers the 180 Trusts who had admissions of more than 5 patients in November 2011, 60% of the worst performers were FTs, whereas only 51% of the best performers were FTs.  FTs are systematically poorer performers than other Trusts in this measure.  And they are meant to be better at self- governance!

Blog Post Updated on Monday 23rd January 2012, 16:00, to include bring out the fact that Foundation Trusts were disproportionately poorer performers.

Response to story about Barts

I have had unprecedented traffic on my story about the resignation at Barts and the London.  Usually, the traffic peaks in the 24 hours after publication.  This time, however, it is still going strong 60 hours afterwards.  And I was also alerted by a concerned colleague that Peter, the CEO, was onto me.

I thought that I would give an insight into why I wrote the story.  After all, my time in the NHS may well be limited.  I can picture it.  A full Trust-wide meeting, and Militant Manager is asked to stand up.  "We know who you are.  We have tracked the IP footprints."  There are only two ways it can go.  There could be a Spartacus moment (thereafter renamed the Militant Manager moment); or I am lead away whimpering like a 6-year old girl.  So given my time with you is limited, I thought I would say something about why I wrote the piece.

It was primarily about balance and scrutiny in the media.  I get irritated by lazy stories - as you can read on this blog entry.  That is how I felt about the resignation story as reported in the press.  My feeling was that people had rushed to the most convenient headline - NHS cuts:

• The Independent: Inquiry launched after leading surgeon resigns over NHS cuts
• The Guardian: Patients physically harmed by NHS cuts and bad management, says surgeon

The stories lack context.  All of us have seen appalling situations in NHS hospitals - even the best of them.  And things go wrong.  It happens.  To get to the bottom of the situation needs more analysis, and context.  It is not always about cuts.

And that is what I was providing.  As you can see, my biggest issue was the stories did not address the agenda of the person involved.   I published what struck me as the potential agenda.  I could well be wrong.  But it made you think, didn't it?

And the rest (including me) is now history.

Another non-story parading as a story

Militant Manager gets irritated by journalists who print a story with the most convenient headline without looking into the agendas of those involved, the context of the story and an opportunity for someone else to put the converse point of view.

For example, take this article by a journalist I quite like - Martin Beckford - on the rise of dementia patients in hospital.  The headline screams that emergency admissions for dementia has risen 12%.  There are so many things wrong with it.  First, it is an odd use of statistics.  The 12% rise figure is not an annual figure as most of us would assume, but actually the rise over 4 years - so actually the annual rise is 3%.  But the headline is cheap when you take it over 4 years.  Second, what do I compare it to.  How have emergency admissions been rising overall?  What is the rise in other conditions?

The other thing is the article only gives paltry information on the context.  You really have to dig to find out that there was a National Dementia Strategy in 2009.  And in February of this year there was a £2m ad campaign (though that would not have really affected these figures).  And coding has been improving over this time.  So in that context of raising awareness, and greater sensitivity to dementia, 12% over 4 years does not alarm me.

Then, what about the agenda of the people promoting the report.  It is MHP Health Mandate, a PR/ lobbying/ communications (you pick) company and the Alzheimer's Society.  Would you think they would have an agenda>  And if that is the most extreme they can paint the statistics - which when put into context is not really that surprising - then the numbers cannot be that alarming in reality.

The report, however, does not really address these points; and then goes on to quote only people from these bodies.  We know how it works - either these quotes are already on the press release, or the promoters make available well briefed individuals to interview.  It is much more difficult for the journalist to find context, agendas and contrary points of view - so they generally suffer.

While we are on the topic why are press releases written in the third person.  Are they not issued by the organisation themselves; and therefore should they not be in the first person.  Is it to make it easy to reprint without alteration?  I really do not know the answer to this question and would be interested in finding out.

I must say that I am concerned about dementia.  It is an issue that we need to grapple with in its right proportions.  And I am glad there are groups that promote its awareness and impact.

My issue is with those who consume those reports, and re-report it.  They/ we need to put it into context.   If that does not happen, it irritates Militant Manager; and hopefully it will now also irritate you.

Noble resignation or convenient excuse to focus on greener pastures

So a Consultant Trauma and Orthopaedic surgeon resigns from his post, blaming management incompetence
in an email [to colleagues?]: cue headlines about NHS cuts harming care.  I am talking about William David Goodier who is set to leave Barts and the London at the end of this year (according to his email).

On the face of it this is a noble act by a doctor who could not in good faith meet the needs of his parents and sacrificed his cherished NHS position.  So thinks fellow alliterative blogger Ferret Fancier.  And Mr Goodier's email is full of detail about the valiant struggle against infernal odds.  If one reads it with violins playing on the gramophone, one can vividly understand what Dr Wilson must have endured on his struggle to the South Pole in the doomed Tera Nova expedition with Scott.

However, Militant Manager is a very cynical sort.  And when a 50 year-old orthopaedic surgeon leaves his NHS practice, Militant Manager's antennae are up and alert.  For I suspect that this has less to do with idealism and struggle; and more to do with filthy lucre.

I have nothing to offer but circumstantial evidence.

First, let us take Mr Goodier's age - just at the inflection point where there aren't sufficient years of practice to justify additional investment in training and education .  So further experience in the NHS is no longer necessary - and all the skills needed to fleece private patients have already been gained.

Secondly, let us look at his (extensive) private practice:

• London Sportscare - a sports and musculo-skeletal chambers run by BMI London Independent (as part of the subsidised support many private hospitals offer to their practising doctors).  Under this guise, he has two weekly clinics, and a weekly operating list.
• London Limb Reconstruction - another chambers, this time run by HCA's hospitals, and based mainly at the Princess Grace.   In this case, Mr Goodier can only do patients on an ad-hoc basis (presumably because his NHS practice timetable does not allow him to make more persistent commitments)
• Medico Legal practice - providing personal injury and medical negligence reports for both plaintiffs and defendants

 Third, let us look once again at that resignation letter.  It is a bit of a rant.  But certain clues can be gleaned:

• Flexible working request.  The letter suggests that he made this last year.  Aaaahhhh, right.  Now, let me see.  Would that allow the aforementioned Mr Goodier to be able to make a stronger commitment to Princess Grace?  Conveniently so!
• The "Non" Issue.  So one of the precipitating issues was the lack of movement in appointing the "second pelvic surgeon." But this post was approved and appointed well within a year.  Most of us (admittedly those of us older than 7) would see that as a pretty reasonable (if not rapid) time frame in the NHS - especially if we had been exposed to the NHS for 30 years, 15 as consultant.
• Demand/ capacity issues.  Mr Goodier writes "Unfortunately, there has been a relentless increase in the workload . . ."  Yes, David.  That is right.  That is one of the underlying problems in the NHS.  And 1m others are putting up with, and rejoicing in it.  But I agree with you David, the NHS would be far better if we did not have patients (wait, let me read that again).
• "Are we there yet?"  Mr Goodier complains that a further 2 consultants have not been finalised.  But wait - it is being worked on right?  And you have clinical leaders in Michael Walsh and Constantio Pitzalis also supporting this right?  And you are older than 7 right?  So can you recognise that it will take time, but we will get there.
• Lack of organisation.  Mr Goodier is unhappy with the organisation of theatres, beds, etc etc.  Is that also not your problem Mr Goodier?  As a consultant there for 15 years, do you not share both the blame, and the responsibility to put it right.  Or are you going to take your ball and go home?  Wait, I forgot that I was using a child under 7 as the metaphor: "Are you going to throw your toys out of the pram?"
• Unprofessionalism.  When somebody does not have the skills to lead a solution, or the emotional intelligence to identify and follow an appropriate leader, they resign; and when doing so, they send a long diatribe that damages the organisation, their colleagues and themselves.

I think this is pretty strong circumstantial evidence.  Overall, my conclusion is that Mr Goodier is not so much driven by ideals as much as by money.

There is nothing wrong in moving to earn more money.  But I do object to somebody who does not have the maturity to distinguish what is a noble struggle, and what is blatant unprofessionalism.  I just wish he had had the decency to thank his NHS colleagues for the years of training and support, and wished them luck in dealing with the challenging needs of inner-city East London.  Mr Goodier, however, lacks such class.

Maternity's flaw is not midwives or quality, but economics

Maternity care is much in the news.  Many of MM's readers would have followed the BBC Panorama report on London's maternity care.  The programme concludes that 17 deaths could have been "avoided" in London in 2009.   Yet, this is not new.  There have been stories about the difficulties faced in and by maternity departments for a long time.  The question is why so much attention and is it deserved?  Is there something underlying that is at work and needs fixing, or can it not be avoided?

It could be because of a number of unavoidable reasons.  It could be related to the primordial nature of maternity.  It is when a new life emerges into the world; where our urge to procreate bears fruit.  The attention could be a result of the scale of loss when obstetrics goes wrong.  After all, nobody is “ill.”  And both mother and baby are relatively young.  If these were the reasons why maternity gets so much attention, then there is not much you can do to avoid it.

But MM thinks there is an avoidable problem that underlies these issues.  It is not easily seen, but lies there and manifests itself in poor staffing ratios; lack of doctors on the ward; high rates of vacancy and agency; poor infrastructure and so on.  All of these issues then give rise to problems and incidents.  This fundamental problem is economics; money; lucre - whatever you term it.  Maternity care does not pay for itself in the NHS. 

That may be a bald statement to make, but can be backed up by a detailed review of the economics of maternity.  Militant Manager has built an economic model of a maternity department to illustrate this economic problem (available on request).  At 4,000 births, the model concludes a Trustwill lose c. £2.8m pa, and £3.7m at 6,000 births.

The model was built using publicly available staffing and productivity guidelines.  Many of these are from the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).

Some of you may be thinking that the sums do not work because MM has taken the guidelines from those with a vested interest.  The Royal Colleges are hardly going to suggest meagre staffing.

MM would, however, disagree that this is a fundamental problem – partly because some of the numbers makes broad sense; and partly because the producers also have interests which moderate the financial call.  For example, the RCOG guidelines suggest that units with 4,000 births should have a consultant on the labour ward for at least 40 hours per week and those with 6,000 should have one for 60 hours.  This is ludicrous.  Firstly, it shows an attempt at reflecting the economics, and moderating the call for the number of consultants by paying attention to activity.  If such an attempt was made, then they should have gone the whole and way, and modelled it out.  They would then have realised the parlous state of maternity finances. 

Secondly, and more importantly, each birth is a birth. Should the RCOG not focus on the care given to each birth, and treat it equally?  Why should some babies have a better chance of obstetrician cover?  It is a bit like when a job applicant answers the question “why should we hire you?” with an answer that talks about what they can get out of the job, and how they will enjoy it.  To be frank, that is not very relevant to the company doing the hiring.  The question is how will the company benefit - and in this case, the baby.

Lastly, and most importantly, how can a clinical (not managerial, efficiency or productivity) standard be any different from either zero or 168 hours cover a week?  Births do not follow time patterns, so if a clinically safe birth can happen without an obstetrician on the labour ward, then it is safe that all births happen that way.  Conversely, if a clinically safe birth cannot happen without an obstetrician on the ward, then no births should happen without that.  There is no space for a fudge. 

MM believes that the issue is that people like the RCOG try and solve the fundamental problem of economics in other ways.   The economics does not support great consultant cover; but rather than recognise this fundamental fact, these bodies try and nudge up standards a little at a time, and put the pressure on Trusts to solve it.  Other attempts act in a similar way: for example, the CQC’s publication "Towards Better Births" which aimed to show the distribution of maternity provision, and nudge up standards.  And another is the BBC's Panorama survey.

Fundamentally, however, the issue is that the economics do not add up.  No private provider is working hard to become an elective or AQP provider of maternity care - they are for orthopaedics and other areas.  No Foundation Trust is building spanking new maternity wings - they are building Cancer Centres.  Lots of Trusts are rationing care, and closing their list to non-local geographies.  The numbers do not work.

When the economics do not add up, Trusts do not invest in staff and resources to give good care.  As all good economists know, economics drives our behaviour - even when we do not realise it.  Trusts do not mean to do it; but they do it subconsciously.  The end result is that care suffers, and we get headlines.

The best solution would be to drive up tariffs. 

Why consultants need more natural predators

Without natural predators, growth in consultant numbers is uncontrolled.  This is the conclusion you reach when you look at the training numbers of doctors through an "ecological" prism: where doctors are the fertile mothers, and registrars in training are the juveniles who will grow to become future doctors.

Replacement fertility measures "the total fertility rate at which newborn girls would have an average of exactly one daughter over their lifetimes" who would go onto have further children. In more familiar terms, women have just enough babies to replace themselves.  It is a bit sexist to define this in terms of women alone, but as 50% female, Militant Manager does not mind.

In a stable ecology, replacement fertility is determined by a number of factors.  First is annual survival rates - the chance that you may die each year (predators, lack of food, disease etc).  Second is the age at maturation (the age at which a female can have children).  The lower the rates of survival each year, and the greater the age at maturation, the greater the replacement fertility.  And this equilibrium is stable because if numbers increased, then survival rates would drop as the population became easier to hunt, or they exhausted their food supplies.  A picture of a cow with an element of its replacement fertility is included for completeness below.

  

On this basis the replacement fertility for hospital consultants is 1 - i.e. consultants only need to have one registrar in their career.  And given 30 years of consultancy (which may increase if retirement is pushed back), and 6 years of training, the stable ratio of consultants to juveniles is 5 (this is 30 years of fertility in the consultant, divided by 6 years of maturation in the registrar).  The child bearing years are so long, the maturation age is so early, and the survivorship is so good, that in a stable population there would be 5 consultants per registrar.

And what ratio do we have today?  We have 5 times what we need, as illustrated in this spreadsheet, and summarised in the table below. 

Of course, the model needs to be adjusted for the more complicated reality.  People retire early, or change career.  There are some who go part-time (often the case for women); and others who go "private" entirely or in part.  There are even some who go to the dark side and become managers.

But these complexities only change things at the margin.  The replacement fertility ratio in humans is higher than the theoretical 2 (the theoretical figure).  This replacement fertility ratio ranges from 2.1 to 3.4 depending on country.  And similarly - though Militant Manager has not seen such an analysis - the stable ratio of consultants to registrars may be around 3 to 5:1.

Yet, we have a ratio of 1:1.  My spreadsheet is based on numbers published by the Information Centre.  This shows how the numbers have deteriorated over the last few years.  One can also see that vacancies for consultants are at negligible levels - the levels at which changes in recruitment practices in Trust will affect the numbers.

The more astute amongst the readers will be pointing out that I have not considered the growth that would be required.  That is by design.  The reality is that in a stable advanced economy, one cannot increase the workforce engaged in a sector without also saying in the same breath that that sector will also account for an increased share of GDP.  The UK already spends 8-9% of GDP on healthcare, and I do not see a groundswell to increase this further.  In fact, national policy is to reduce the share of GDP healthcare absorbs by keeping public spending on it constant as GDP grows.  So there are no grounds to independently plan for rapid growth in doctor numbers.

So what does this all mean.  I have four main thoughts:

1.  NHS Workforce leads should be sacked.  Not only have they allowed this to arise, they are asking the wrong questions.  Militant Manager has searched for years for strategic analysis of training numbers - what numbers do we need; and what drives the replacement ratio.

2.  There is going to be a lot of pain for trainees.  There was - not so long ago - a role for "senior registrars."  They were effectively registrars who had all the requirements for consultancy, but had to do "their time" waiting for a job to come up.  It was not unusual to be in such a stage for 5 years.  Those days are coming back.  And the 5 years will be used to erode, demoralise and reduce the registrar base.  Many will leave the profession, and lots of others will seek other ways to burnish their CVs to distinguish themselves in an the increasingly competitive process of becoming a consultant.

3.  We need a better plan.  Juniors now do a lot of activity in hospitals; and many rotas require them.  So in some respects there is a requirement for this number of registrar level doctors.  But we do not need those numbers "training" and aspiring to consultancy - an aspiration we cannot meet.  That will require a reduction in training throughput, and a change in the stable workforce mix in hospitals - away from "training" posts.  This is a task that will have to be picked up by the new HR directors who replace the sacked ones.

4.  We need more natural predators for consultants. Ideas include taking consultants and leaving them in the serengeti; encouraging more to go camping in Siberia; and introducing diving in the shark infested waters of South Africa as a training requirement.  

Readers will have better ideas, and I would welcome those.

The wrong call for the Ambulance Service

The National Audit Office produced another report this month.  This time it was on the Ambulance Service.  And its headline finding was that the focus on response times had caused inefficiency in the system.  This is such a muddled finding, that Militant Manager does not even know where to start.

But let me try.  I think you can justify response times in three ways.  Firstly, it is a common sense target.  Secondly, its robust and meets all the criteria for targets.  Thirdly, the "inefficiencies" that the NAO finds are due to an incomplete analysis.

First, let's try the common sense approach.  Response times is what Joe Public expects from his ambulance service.

I can demonstrate this through a thought experiment.  We are going to ask somebody what they feel is an appropriate target for the ambulance service in this experiment.  Imagine we are in Sheffield city centre on a Saturday morning - shopping time - bound to find lots of people.  But wait - those idiotic 1980s town planners thought it would be a good idea to open a huge shopping centre near the M1 - Meadowhall.  So we cannot find anybody.

Luckily those town planners tried to cover up their idiocy by commissioning the Winter Gardens, and that is where we find Aron Ralston (not Joe Public unfortunately).  We ask Aron the simple question: "If you had to think of a target for an ambulance service - a target that they would then pull all stops to meet - what do you think it would be?"  Aron is a bit strange, saying "The key target should not be response time - I do not mind if it takes 127 hours; what I want as the target is the handover time and information sharing at the hospital?"

The difficulty of imaging proves my point that response times is the common sense target, and you need to go to the Winter Gardens in Sheffield to find anybody who does not think so.
Secondly, the target meets all the criteria that you would want a target to have.  Better people than me have worked this out as SMART targets.  Specific, Measurable, Attainable, Relevant, Timely.  Response times fits all those criteria to a "T."

The third issue is the key one.  The NAO analysis is incomplete.  It focuses purely on the unintended consequences of the policy - more than one ambulance scrambled for Category A calls, and then stood down; but not on the other aspects - the intended consequences; and what would have happened under an alternate policy environment.

There are many aspects to every policy and its effects.  Militant Manager has created a handy two-by-two matrix to illustrate all the aspects (MM should have been a management consultant).  You can find this matrix here.  Causes are split into "Policy" and "Other factors" and Effects are split into "Intended" and "Unintended."

All policies will have unintended consequences.  And the NAO has focused on the unintended consequences of the policy, quantified them and published them as avoidable inefficiencies.  It is a bit like looking at a football match, identifying all the shots that missed the goal, and then figuring out the "points lost" as a result of those missed shots.  Yes, that is interesting and difficult analysis, but in itself it tells you little: what you can control is the shots; not whether it misses or not.

The true answer lies in looking at both the unintended and intended consequences, quantifying both; and then comparing all of this to an alternate policy environment.

One would well argue that the dual scrambling of ambulances is caused by this response time target, but so is better response times (the intended consequence) - which would have resulted in greater public satisfaction benefits, as well as clinical benefits.  You need to consider them all in the round.

And then you need to consider them against at alternate policy.

The NAO's alternate policy is a bit weak.  Some amorphous set of indicators, which may not comply with public expectations, be SMART or result in pure good effects.

********

My main quibble is what the NAO has decided to lead with in its public announcements: the response time target - which is robust, SMART, well accepted, and, on balance, desirable.  The actual report has some other very interesting findings which do point to the inefficiency of ambulance services: 5-8% sickness rates, increasing costs per trip, reducing labour productivity . . .  None of these are caused by or cause the dual scrambling.