The ‘Cost of Zero Cost’ Paradox

Medical doctor writing and taking notes on cliboard in hospital setting

What a fantastic week we had at the Primary Care Best Practice Show at the NEC in early October. We had the privilege of connecting with inspiring individuals who are deeply committed to innovation and enhancing the quality of service for the communities they serve. Throughout the event, we engaged in numerous discussions revolving around the challenges faced in Primary Care, and, of course, growing demand and workforce pressures were hot topics of discussion. Surprisingly, amidst these crucial topics, the conversations that resonated the most at the Caja stand were centred around the notion of ‘Customers’.

Primary care is often the first point of contact for individuals seeking help, advice, and guidance on their health. However, the relationship between GP Practices and the public is complex, influenced by various factors that shape people’s perceptions, actions, and behaviours. Internationally, the NHS is the blueprint for a nationalised healthcare system with strong socialist principles, prioritising healthcare based on clinical needs rather than financial means. Whilst this philosophy is fundamental in shaping expectations, it often contends with the wider reference points that also shape our expectations and thinking.

We live in an era marked by ever-advancing technology and consumerism, where instant gratification and satisfaction hold significant value in our daily lives and experiences. Yet, what dominates the Primary Care narrative?

An overwhelming demand for services and the struggle to secure timely appointments, waiting days for consultations, and the infamous 8 a.m. phone call lottery. Whether perceived or actual, these factions begin to explain the decreasing satisfaction levels (patients saying their overall experience was good) evident in the NHS National Patient Survey, with a 12% decline since 2019.

In our interactions with primary care providers, it’s interesting how frequently we encounter frustration about patient behaviours and the ostensibly ‘unrealistic expectations’ that have emerged. How aware are individuals of their decisions and behaviours in their interactions with health services and broader public services? Research has shown that around 90–95% of our brain’s activity is subconscious. Consequently, most of our actions and decisions depend on brain activity beyond conscious awareness, so we don’t generally apply logic as to why services don’t (or can’t) meet our expectations – why would we? It’s not our problem as ‘customers’. Therefore, simply trying to inform or educate people about how and when they should use services is unlikely to alter behaviour effectively.

In the Caja office, Dan Ariely’s book ‘Predictably Irrational’ is a favoured read; he challenges conventional assumptions about human decision-making, revealing that rational thought doesn’t solely guide our choices. Check out the chapter on the Cost of Zero Cost’; maybe the NHS principle of free at the point of use makes us value it less? Ariely’s experiments demonstrated that when something is available for free, individuals often disregard its true worth when making decisions.

This brings us back to the notion of ‘Customers’, discussed on the Best Practice Show stand, which is not a term often used in public services, and Primary Care is no exception. However, the ‘Customer’ concept is generally lesson 101 for Service Improvement practitioners. A key question frequently posed and considered in most sectors when aiming to delight and retain customers is, ‘Would the customer be willing to pay for what you are doing right now’? This question helps identify what customers genuinely value and is at the core of world-class organisations’ operations.

Consider Amazon, a global company with over 300 million customers, shipping more than 1.6 million packages daily. Their customer satisfaction rates are almost legendary, with the American Customer Satisfaction Index (ACSI) ranking Amazon first in measures such as customer loyalty, service quality and meeting customer expectations. Amazon has a well-published set of leadership principles, with the first principle being about ‘Customer Obsession’. Leaders start with the customer and work backwards, diligently focusing on earning and keeping customer trust. So, in response to the critical question, ‘Would the customer be willing to pay for what you are doing right now?’ Amazon’s net revenue in 2022 was over $500 billion US dollars.

Reflecting on my conversations at the Best Practice Show, my challenge to comments about overwhelming demand and long waiting times was to reframe the discussion to ‘Customers’ – ‘Would the customer be willing to pay for what you are doing right now?’. Unsurprisingly, it was difficult for professionals and managers to answer that question positively. Whilst the ‘Cost of Zero’ might mean we don’t immediately consider the value of NHS services as individuals, a greater focus on the customer perspective and value creation will inevitably enhance experiences and outcomes.

To achieve this, a paradigm shift is needed in how Primary Care approaches improvement. Rather than the traditional approach of starting with a service-centric focus and attempting to educate the public, Caja advocates for an external perspective that places customer value and behavioural influence at the forefront. Such an approach holds the potential to reshape both perceptions and expectations.

In the words of Peter Senge, ‘’People don’t resist change. They resist being changed’’.

At Caja, we are change facilitators with a profound commitment to making real-world difference. Our CognitivQI™ methodology seamlessly integrates Operational Excellence and Behavioural Science best practices, empowering teams to forge synergies between People, Process, Data and Technology Enablement, ultimately creating sustainable change. Our team’s motto is ‘customer-focused, community-driven’, and we wholeheartedly embrace this philosophy in every aspect of our work, driving us to innovate continually and elevate the experiences of our customers and their communities.

Please don’t hesitate to reach out if you have any questions, or have an internal initiative we can support you on. We’re here to help!

Contact us at or 01782 443020 for any inquiries.