Matt Morgan: Marginal gains and major fails

I’m often amazed by the slim margins that separate success and failure. At the 2024 Summer Olympics, Noah Lyles won the men’s 100 m sprint by just 0.005 seconds, with the top seven athletes all finishing within 0.09 seconds of each other. Marginal gains—an economics term popularised by a former performance director of British Cycling, Dave Brailsford—play an important part in training and winning. Even an athlete’s hairstyle can mean the difference between winning and losing these races. Long curly hair or loose fitting clothing can add 0.07 seconds to a finish time, which would be enough for Lyles to have missed out on a gold medal.1

It’s no wonder that this science of success has been applied to healthcare. To prevent us being blinded by the obvious, however, we must recognise the huge difference between elite sport and public health systems. A new feature published in The BMJ details the abysmal, crumbling state of UK hospitals, including those in Wales, where I work.2 Against this backdrop of constant sewage leaks, broken sinks, and a lack of isolation facilities, people are doubling down on marginal gains to save the day. The posters telling us to “roll up our sleeves,” “take off our watches,” and “only wear wedding rings” have become bigger and brighter, in bold block capital letters.

Rather than being used in combination with long term, sustainable fixes, marginal gains alone are being used to tackle the major failings that affect patient care. Often, these marginal gains lack evidence and are little more than a loin cloth used to cover the embarrassing state of NHS infrastructure, which isn’t being fixed owing to a lack of funding. It’s a bit like me shaving my legs to improve my 50 m swimming time while using doggy paddle rather than swapping to freestyle.

For those of us working in healthcare, this is more than just an irritation. It can drive a wedge between the clinical staff affected by such meaningless policies and those who are enforcing them. The term “moral injury” is increasingly used to describe the psychological, emotional, and spiritual distress that arises when someone perpetrates, witnesses, or fails to prevent actions that conflict with their deeply held moral or ethical beliefs. I would like to suggest a new term: “logic injury.” This describes the psychological, emotional, and organisational distress that arises when someone perpetrates, witnesses, or fails to prevent actions that are entirely illogical or are out of proportion with other interventions that are far more meaningful but not done.

I don’t pretend that the challenges involved in tackling a creaking healthcare estate are simple to solve. But neither are the complications that arise from not doing so. Simply berating the people most affected by the illogical policies that act as a shadow to cover the underlying poor state of buildings will only result in more gold “wedding” rings being worn, rather than gold medals being given for patient care.