A small minority, a big impact on public services
After a recent two-night stay in hospital, I came away with an uncomfortable thought: much of the NHS still works remarkably well. The bigger problem is how a small minority of people use it.
That risks sounding like patient-blaming. It isn’t. Most people use public services appropriately—often reluctantly and with real gratitude. Staff are under pressure. Workforce gaps are real. Demand is rising. All true.
But it is also true that a minority of people create a disproportionate amount of additional work. And in already stretched systems, that matters.
As a patient—and someone who has spent a career around public services—I saw both sides. What is routine for staff is largely invisible to the public, and often avoided in public debate.
My own experience was what the NHS at its best looks like. What began as a cold escalated quickly. On arrival, my observations were taken promptly. The decision to admit was made without delay. Within a few hours I was on a ward, tests done, treatment started. After two nights, I was well enough to go home.
That is not a system failing. It is a system working.
But what I saw around me tells a different story.
On my first night, one patient’s behaviour dominated the ward. Shouting. Swearing. Abusing another patient. He required one-to-one nursing—not for clinical need, but to manage disruption. That is a member of staff diverted from patient care.
Another patient insisted on leaving against medical advice. The nurse in charge spent a long time trying to persuade him to stay. It emerged he had been off the ward drinking. He signed himself out. Then asked staff for money. It was hard not to think he would soon be back.
In my bay, most patients had diabetes. Several admitted they had not managed their condition seriously. This is not unusual. A significant proportion of hospital activity is linked to long-term conditions that could be better managed outside hospital.
None of this will surprise NHS managers. Nor will it surprise those working in other public services. The pattern is familiar: a relatively small group accounts for a disproportionate share of demand.
Anyone working in housing, social care or policing will recognise it. A small number of tenants generate repeated complaints and enforcement action. A small number of individuals account for a large share of social care time. A small number of people come into repeated contact with the police.
The NHS is no different.
The data reflects it. A relatively small group of “frequent attenders” account for a disproportionate share of A&E use—around 10 per cent of patients accounting for up to 30 per cent of attendances. That is repeated demand that services are not designed to absorb indefinitely.
The NHS is not overwhelmed by everyone. It is strained by patterns of use it was never designed for.
This is not about denying care. Some of this behaviour reflects wider issues—addiction, mental health, poverty. But not all of it.
Every avoidable admission, every episode of disruptive behaviour, every unreasonable demand adds friction. It slows flow. It blocks beds. It absorbs staff time. And it affects others—often those least able to advocate for themselves.
We need to get better at distinguishing between need and behaviour—and being clearer about the difference.
Those running public services already know this. They deal with it every day.
The harder challenge is saying it out loud.
We are comfortable talking about resources. Less so about behaviour and expectations.
Until that changes, a small minority will continue to create a big impact—not just in the NHS, but across public services—and the system will continue to absorb the cost.
Blair McPherson former Director author and and blogger blairmcpherson.co.uk
