It’s simple…
The NHS is the monopoly employer of doctors, and…
… when they go on strike, they have the NHS over a barrel.
The DH+ have no strategy to deal with strikes, other than trying to manage the risks and eventually, paying hostage-money.
When the Thatcher government took on the miners, they had a strategy. They built up stocks of coal. Devised an energy policy to end dependency on coal.
When Ruper Murdock took on the print unions, he secretly built a high-tech print factory, that didn’t depend on traditions skills.
The NHS is faced with unionised-medics. No serious employer would just sit back and wait to be held to ransom.
Maybe the DH+ isn’t? Perhaps they’re cannier than we give them credit for?
Tucked inside a seemingly routine response to industrial action is a line that ought to set alarm bells ringing across the NHS.
A move to;
‘design services that are…less reliant on resident doctors.’
Not a contingency. Not a workaround. A direction of travel.
In plain English, what it means is; the NHS is operationally dependent on a workforce it can’t control.
Resident doctors are numerous, mobile, central to day-to-day care and crucially, now willing to strike.
In system terms, that is called a ‘single-point-of-failure’.
The response, in terms of good management… remove the dependency.
That doesn’t mean fewer doctors overnight, but…
… it does mean changing how work is done. Change that and you can change the people doing the work.
It’s already happening in plain sight.
First, substitution.
Tasks once firmly in the domain of resident doctors are being redistributed.
Controversially to advanced practitioners, physician associates. Specialist nurses and pharmacists, all well entrenched.
This is reshaping skill-mix.
Second, standardisation.
Medicine is being broken down into pathways, protocols and algorithms. If you can turn clinical work into a series of …
…if this➝then that… decisions…
… you reduce the need for highly trained generalists at the front line. Same-day emergency care, surgical streaming, virtual triage, all are part of this shift.
Less judgement, more process.
Third, consultant-isation.
During strikes we saw more direct consultant-involvement, quicker decisions. In some cases, shorter lengths of stay. It looks attractive, but…
… today’s service runs on tomorrow’s trainees. Hollow out the training pipeline and you create a future workforce problem that no amount of clever modelling will fix.
However, withdrawing a 1,000 training posts, fits a work-shift narrative.
Fourth, digitisation.
The quiet revolution. AI-supported triage, remote monitoring, virtual wards, diagnostic interpretation, patient-initiated follow-up. Each shaves-off a little of the need for doctor-time. Not dramatically, but cumulatively enough to change the shape of the service.
Put it together and the model begins to emerge: less doctor-centric, more system-led, more protocol-driven, more dependent on technology and a wider clinical workforce.
On one level, this is overdue. The NHS has long relied on a model of relatively inexpensive, highly trained junior labour to keep the show on the road. That bargain is breaking down…
… the strikes have exposed it, but …
… let’s not pretend this is a risk-free redesign.
There is a fine line between skill-mix and skill substitution. Cross it and you invite missed diagnoses, over-reliance on protocols and a culture of escalation ‘just to be safe’. Demand doesn’t disappear; it shifts, often upwards and expensively.
There’s also the question of behaviour.
Systems adapt. If clinicians learn how to work the protocols, route around responsibility or escalate early, the anticipated efficiencies evaporate. We have seen this movie before.
Then, there’s the workforce reaction. Doctors will see this for what it is…
… a structural response to the fulcrum point of their growing leverage…
… it’ll be read as de-skilling by design, pay restraint by proxy and ultimately, replacement strategy.
That’s a row waiting to happen.
Finally, the biggest risk of all… training. The NHS is built on an implicit deal… today’s service is delivered by tomorrow’s specialists in training.
Undermine that and you are borrowing from the future to pay for the present.
This is a pivotal moment.
A more flexible, resilient NHS, less exposed to single points of failure, is an entirely reasonable ambition, but…
… healthcare is not a factory. You can standardise processes; you cannot standardise uncertainty.
Substitution has worked across most of the professions, architects, accounting, legal, there’s no reason to believe healthcare is any different, until…
… you have to deal with a nurse strike or a radiographer walk-out.
Only then do you realise…
… there’s no substitute for good industrial relations.
News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.
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