The NHS is under super enormous pressure. Staff are walking, patients are waiting ridiculous amounts of time, and services feel harder to deliver than ever. Why? Not enough funding? Debatable. An ageing population? Definitely a contributor. Political decisions that make you want to scream into a pillow? God yeah.

“If only we had more doctors, more nurses, more beds, more stuff...” But what about how we use the workforce we already have? Billions are funnelled into recruitment drives and shiny tech, yet in the shadows small cultural habits might be quietly draining the system every single day.

Now, I’m gonna bravely approach one, often untouchable topic that needs a wee tickle…

Medics are brill, aren’t they? Highly trained, hugely valuable, and often super dashing. Buuuut as lovely as they are, they shouldn’t be ‘untouchable’.

Now, I’ve set this up nicely so let me tentatively whisper that concern of mine. In medicine there are some patterns of behaviour that often go unchallenged…could they be contributing to the problem?

Ok I’ve said it, so let me see how far my bravery will take me.

1. Clocking in Late, Leaving Early

Picture this: a patient has an 8am appointment. They got up early, skipped breakfast, battled parking (which is as expensive as a weekend in Amsterdam) and arrived on time. By 08:15 they’re still waiting.

Why? It’s the start of the day? Maybe the doc started at 07:30 and one of the first patients was super complicated? Oorrrr (takes a bravery pill) maybe it could be because the doc’s tennis lesson overran and they’ve only got into work at 08:10.

I’m being jovial of course but I’m leaning tentatively toward a serious point. Some docs seem to be stretching things like this, rocking up rather late and leaving early. Maybe it’s the odd one or two, but if it’s not, do we need to start questioning why it’s so easy to be so liberal?

And let’s be honest, other staff notice. Nurses who’ve been at handover since 07:55. Physios who can’t leave until their last patient’s safe. Junior doctors terrified to leave until the jobs list is cleared. When seniors slide in at 08:10 or sneak out at 15:30, what does that signal to colleagues and to patients? If the public saw how casually we treat 15 minutes at the start of a list, they’d be horrified.

It seems that when accountability rests with an operational manager who lacks authority, and a consultant lead who might also be a peer, a bit too much flexibility might be on offer. After all you ain’t gonna have a go at your golf buddy.

I’m not calling for a culture of micromanagement but I am calling for a system whereby holding people to account is attainable.

2. No Accountability for Best Practice

Variation from best care happens, in fact I’d argue that’s a good thing buuuuut it’s shouldn’t be like, all the f*****g time 😆. Subacromial decompressions (SADs), trigger point injections, scopes on nans. It’s a bit much isn’t it. If I could set a KPI for T&O it’d be the ratio of scopes to nans per year and you’d wanna be going for 1:100.

I joke, I think (I’ll mull it over) but I do wonder how much outdated practice like this is costing the NHS? Probably enough to hire an extra nurse for A&E.

And it’s not just about money.

It does suck - imagine being sat on a pain management waiting list for 2 years; two years of losing physical and mental health and the prize at the end is an intervention that barely works. I do have empathy for medics here. I assume that by the time a patient gets to that point, our medical colleagues assume that they’ve had a great journey of care and maybe, through a place of empathy, a ‘hail mary’ is worth it. Did I assume too much there? I’ll assume I did.

Then there’s the impact on the flow of the entire system. Every unnecessary arthroscopy is not just £1,500 down the drain, it’s also a patient waiting three months longer for their diagnostic colonoscopy. Opportunity cost is the bit that stings: outdated practice isn’t neutral, it actively blocks innovation and slows access for those who really need it.

So what do we do?

Well, what if, instead of tracking DNA rates, we openly tracked adherence to best practice? Could transparent national data give managers clarity, patients reassurance, and clinicians stronger feedback loops? Shine light on those blind spots? Give ops leads, commissioners and the public something to really dwell on?

If we put in as much effort to tracking adherence to best practice as we do DNA rates we might just strike gold. Honestly the amount of time spent on monitoring DNAs is so incredibly demoralising. Saving an extra 4 appointments isn’t going to make the difference that our mates in the Department for Health seem to think it will.

My mate Wes Streeting sitting at the top of the tree loves a statement so here you go pal, I’ve sorted it for you. Remember me when you’re warming up Number 10 for Farage (vomits in own mouth).

3. Protecting Roles Instead of Using the Workforce We Have

Does the NHS have a workforce problem? Probably. Could it be less of an issue if a door was opened for ACPs, APPs, ANPs to stretch themselves?

Like, why aren’t ANPs ‘allowed’ to see spines in ED? Genuinely, I’m asking because at the mo I’m worried it’s because the docs don’t fancy them to do a good job. I hope I’m wrong, but I’m worried I’m not.

And why are spines treated like pastry cooking? 90% are dead easy, unlike baking a mille-feuille which is actually really hard to do, as I found out on a really bad date.

Other health systems already embrace this. In the US, ANPs run entire spine triage services. In Australia, physios lead ED fracture clinics. The Netherlands hand Advanced Practice Nurses far more autonomy. And guess what? The sky doesn’t fall. If anything, morale improves, because otherwise talented professionals who feel boxed in eventually leave, which ironically makes the workforce shortage even worse.

Then you’ve got primary care… Over recent years I’ve heard many GPs describing almost unmanageable work loads. I listen to them on social media, in their lunch breaks and on podcasts. What I hear sounds grim but then when I’ve looked a bit deeper the same issue lives there too.

If you’re a service user or a commissioner and your GP practice has a mega grim waiting list, have a browse at how many ANPs or FCPs they have in the practice: it’s often not enough.

The question I’m asking I guess is: are medics (if my suspicion is correct) making things harder for the NHS by protecting territory?

Final Thought

The NHS doesn’t need another leadership framework or an inbox full of wellness emails.

It needs:

* Accountability

* Shared responsibility

* Consequences when behaviours undermine patient care

That means:

* Calling out when people rock up late and leave early

* Refusing to defend outdated procedures that don’t work

* Sharing clinical decisions with the professionals trained to make them

This isn’t about undermining doctors. It’s about holding everyone to the same professional standard. Because each small behaviour - a late start, a pointless scope, a protected territory - has a ripple effect. It means longer waits, wasted money, burnt-out colleagues, and real patients missing real care.

The NHS will not be saved by frameworks or slogans. It will be saved by courage: the courage to have awkward conversations, to challenge behaviours that feel ‘normal’, and to share the load across the whole workforce.

Medics are a core part of the NHS. But if you’re clocking in late and ignoring guidance, you’re making things worse. And if that makes you uncomfortable, good. It should.

Maybe the real trick is easier than mille-feuille: turn up, use best practice, share the load.

So perhaps the real questions are:

* Is there an issue with accountability in medical circles?

* Why do the NHS governance streams seem apathetic toward scrutinising outdated practice?

* And seriously, how do you actually make a good mille-feuille?

This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit mskmag.substack.com/subscribe