Last week I was talking to someone who’d left the NHS to move to a small company offering physiotherapy services. 

They’d left because they didn’t feel they could serve patients properly in the allotted 10-15 minute appointment slots. 

This interested me as when I last wrote about restrictive appointment times four years ago I was assured by a fairly senior NHS leader that it was no longer standard guidance. 

So I thought I’d have another look where this practice came from, and whether it is really changing. 

The origin story of the ten minute appointment slot is from 1986, when a London GP practice ran an experiment: 

Patients were sent, more or less at random, into surgeries booked at five, seven and a half, or ten minutes per person.  

This was to see whether the length of the appointment affected the quality of the outcome.

At five minutes, doctors picked up fewer problems and the patients felt rushed.

At seven and a half minutes patients felt happier, as there was more discussion about their issues. The doctor was asking more, and finding out more.

In the ten minute appointment, doctors spent longer explaining what was wrong, longer explaining the treatment, and longer on prevention advice.  

Roughly: 

• Five minutes was useless 
• At seven and a half minutes the doctor listens more
• At ten minutes the patient finds out what’s going on.

That’s the study. 

And from that experiment in one London practice, by five doctors, forty years ago, the ten minute rule was born and then became the basis for the entire structure of English general practice. 

Indeed, in 2004 it even went into the GP contract with money attached, and you got paid for reaching ten minutes, but nothing extra for fifteen. The exam to qualify as a GP was thirteen ten-minute cases, so every new doctor learned to work at that speed.

The 10 minute mandate for GPs lasted until 2014 when the requirement was withdrawn as unduly restrictive, especially for complex cases.  However,  most appointments in England still last between six and ten minutes. 

So the colleague who told me it was no longer standard guidance was correct: there has been no rule in place for twelve years.

Yet the practice often remains. 

It’s often a lot harder to remove a rule or requirement than it is to create a new one.  

This is sometimes called the ‘Ratchet Effect’ 

A ratchet only spins in one direction and then locks into place, so the Ratchet Effect describes systems and behaviours that easily move forward but heavily resist going back.

The concept started in economics. 

During a crisis (think of airports post 9/11,  or the COVID-19 pandemic) , governments and institutions may raise taxes/prices or create new rules. 

Citizens accept this out of necessity. 

But when the crisis ends, things rarely return to the original baseline. The system has ratcheted up. And it will resist going back.

Since 9/11 we have dutifully surrendered sharp objects and taken off our shoes at airports, because the rule ratcheted into place. But aviation security experts widely agree that the single most effective measure to prevent another hijacking wasn’t confiscating objects—it was simply installing reinforced, locking cockpit doors. We kept the bureaucracy because it was visible, not because it was doing much.

Adding a rule or habit solves an immediate problem. But removing it means disrupting the ‘new normal’, fighting established systems, and spending effort just to go backward. And, if you’re a command and control type, why would you want to remove a rule that people have already accepted? 

It’s worth considering where many of the targets and practices that exist in our organisations come from. 

How many have been purposely designed based on evidence? 

How many incentivise the right behaviour?

How many of them deliver on what end users truly value? 

Pre-empting the Ratchet Effect

If an organisation pilots a new rule or target and realises the evidence does not support it, they can quietly scrap it. 

But once a target is officially rolled out, the Ratchet Effect takes over:

• Budgets are allocated to track it.
• Managers’ remuneration are tied to it.
• The public (or more likely the leadership) come to expect it.

Removing it later looks like a failure, a surrender, or a lowering of standards, even if the target was entirely flawed from day one.

My physiotherapist escaped the ten-minute ratchet. But millions of patients and doctors are still trapped in it, moving frantically to a rule that doesn’t really exist.

This is the ultimate danger of the Ratchet Effect. Even if the mandate is officially withdrawn, the system remains haunted by it. We build our practice, our schedules, and our cultural expectations around a ghost.

If a target in your organisation lacks proof that it actually improves outcomes, remove it now before the ratchet locks. 

Because once it does, you stop measuring success, and you start measuring compliance for the sake of it. You build a system that rewards checking a box, while entirely missing the point.

Photo by Aron Visuals on Unsplash