Did you See It?

There are moments in NHS policy where something important is said so quietly that it is almost missed. Not because it lacks significance, but because it is wrapped in the language of pragmatism, contingency, or operational necessity. Sir Jim Mackey’s recent comments about designing services “less reliant on resident doctors” feel like one of those moments. On the surface, this is a response to industrial action. A sensible, even inevitable reaction to a workforce that has demonstrated both its importance and its leverage. But if you take time to think about it, it starts to feel like something else entirely. Not a workaround, but a signal, because what is being described is not about numbers, it is about the reconfiguration of work.

The quiet shift from “how many” to “who does what”

For years, the dominant narrative in the NHS has been one of shortage. More staff equals more activity. More doctors equals shorter waits. More nurses equals safer care. It is intuitive, politically attractive, and easy to communicate. The difficulty is that it has never quite worked in practice.

There is a well-rehearsed body of evidence, stretching back decades, which challenges the assumption that adding more people to a complex system automatically improves performance. Fred Brooks’ work in The Mythical Man-Month (recently referenced by Steve Black in the HSJ) is often cited in this context. His central observation was disarmingly simple: adding more people to a delayed project often makes it later. Coordination costs rise, communication becomes harder, and coherence is lost.

That argument translates uncomfortably well into healthcare. Recent NHS experience bears this out. Over the past five years, the service has significantly increased the number of doctors, yet activity has not increased at anything like the same rate, and waiting times remain stubbornly high. The explanation is not hard to find. Care pathways are fragmented, responsibilities are split across organisational and professional boundaries, and the coordination required to turn capacity into throughput becomes progressively more complex as more people are added. At some point, the constraint is no longer the number of staff. It is how the work itself is designed.

What Mackey is really pointing towards

This is why Sir Jim Mackey’s comments matter. When he talks about a “blended clinical family” and services that are less dependent on a transient training workforce, he is not simply describing a response to strikes. He is opening the door to a different model of clinical delivery. We can already see the contours of that model emerging.

There is a gradual but persistent redistribution of tasks away from resident doctors towards advanced clinical practitioners, specialist nurses, pharmacists and other non-medical roles. There is a continued expansion of support roles, including nursing associates and healthcare assistants, often positioned as a more stable and locally rooted workforce than agency-dependent care staff. There is increasing use of protocols, pathways and decision-support tools that standardise elements of clinical work and reduce unwarranted variation.

And then there is the growing role of technology. Not as a dramatic replacement for clinicians, but as a steady, cumulative influence. AI-supported triage, remote monitoring, virtual wards, and digital diagnostics are all changing the way clinical time is used. Each intervention is small in isolation. Together, they begin to reshape the service. None of this is entirely new. What feels different now is the context. Industrial action has exposed the degree to which the NHS is operationally dependent on a workforce that is both essential and, at times, unavailable. In system terms, that is a vulnerability. The logical response is to reduce the dependency.

This is not uniquely British

It is tempting to see this as a peculiarly NHS response to a peculiarly NHS problem. In reality, similar shifts are visible internationally. In the United States, nurse practitioners and physician associates have taken on substantial elements of work that would historically have been undertaken by doctors, particularly in primary care and chronic disease management. There is a large body of evidence suggesting that, for defined patient groups and within well-designed systems, outcomes are comparable and patient satisfaction is often high.

In the Netherlands, the deliberate redesign of care pathways has enabled a more distributed clinical model, with a strong emphasis on multidisciplinary teams and clearly defined roles that extend beyond traditional professional boundaries. In Australia, rural and remote services have long relied on expanded scopes of practice, not as a cost-saving exercise but as a practical necessity. What is emerging in England now is, in some respects, a belated recognition of approaches that have been tested elsewhere. The common thread is not substitution for its own sake, but clarity about who does what, supported by training, governance and system design that makes those roles work.

The uncomfortable question about the future workforce

This is where the conversation becomes more difficult. The implicit assumption behind much workforce planning has been that the NHS simply needs more of what it already has. More doctors, more nurses, more allied health professionals. The forthcoming workforce plan has been widely expected to reinforce that narrative, albeit with some variation around skill mix. But what if the underlying premise is shifting?

What if the question is no longer how we grow the workforce, but how we redesign it?

There is a version of the future in which the NHS employs fewer people overall, but deploys them differently. A workforce that is more deliberately structured around the skills required to deliver modern care, rather than the historical accumulation of roles. A smaller number of highly trained clinicians working at the top of their licence, supported by a broader base of practitioners and assistants, with technology absorbing some of the routine cognitive and administrative burden.

This is not about diminishing the contribution of any professional group. It is about recognising that the current configuration of work creates bottlenecks, duplication and inefficiency, often through no fault of the individuals within it. The system is doing exactly what it was designed to do. The problem is that it was designed for a different era.

Why this might actually happen

The prevailing view, reflected in some of the commentary, is that such changes are politically and professionally too difficult to deliver. That they will be discussed, explored, and ultimately set aside in favour of more familiar solutions. But I am not sure.

The financial context is tightening. The scope for simply adding more staff is limited. Industrial relations are strained. Productivity remains under intense scrutiny. And, perhaps most importantly, the gap between demand and capacity continues to widen.

In that environment, redesigning work is no longer a theoretical exercise. It becomes one of the few viable levers available.

The resident doctor strikes have, perhaps unintentionally, accelerated that realisation. They have demonstrated both the importance of that workforce and the risks of relying on it too heavily in its current form. They have created the conditions in which alternative models can be explored with a new degree of urgency.

A moment worth paying attention to

None of this is straightforward. There are real risks. The boundary between skill mix and unsafe substitution is not always clear. Training pipelines matter. Professional identities matter. Patient safety must remain the organising principle. But it would be a mistake to dismiss what is happening as rhetoric or contingency planning.

When Sir Jim Mackey talks about reducing reliance on resident doctors, he is not just addressing a short-term operational challenge. He is, perhaps quite deliberately, signalling a broader shift in how the NHS thinks about its workforce. The question is not whether this conversation will happen. It already is. The question is whether we are ready to engage with it honestly. Because if you did see it, it is quite hard to unsee.