Why the NHS in England is really failing.

I’m a senior doctor in the NHS, and if there’s one thing I’ve learnt, it’s that the issues we’re facing aren’t the result of frontline staff failing to roll up their sleeves and trying their very best. Rather, much of the chaos, stress, and endless crises we read about daily can be traced back to a series of decisions made by the senior leadership team in NHS England (NHSE). These leadership choices have rippled across every trust, every specialism, and nearly every colleague I’ve met, shaping the daily experience of doctors, nurses, and allied health professionals in ways that are often detrimental to patient care. It is the NHS England leadership who either lobby Government for particular policies or are tasked with turning Government policy into reality and yet they are never held accountable and the Secretary of State for Health and Social Care catches a disproportionate amount of the flak.

1. The 2016 Contract and the Erosion of Continuity of Care

Back in 2016, a new contract was imposed on resident doctors which was marketed (at least to the public) as an upgrade that would introduce a “seven-day NHS” and ensure consistent coverage throughout weekends. In practice, this was more about political optics than genuine improvement of patient outcomes. From my perspective, the most tangible change was that doctors suddenly found themselves spread more thinly across more days, with rota patterns becoming more erratic.

One of the greatest casualties of this new arrangement has been continuity of care. Previously, teams were more stable. You’d have a consultant, registrar, senior house officer, and foundation doctor all working in tandem, often on a more predictable pattern. This allowed them to get to know each other’s strengths and weaknesses, to trust each other’s clinical judgements, and – crucially – to follow a cohort of patients through their admission, investigations, and treatments in a more cohesive manner. Patients benefited immensely from the stability of seeing familiar faces, and the medical teams built better rapport with them over time.

After 2016, rotas were rejigged in the name of “efficiency,” with doctors spread out to ensure coverage for more days and more shift patterns. Whilst it might look good on a spreadsheet to have so many doctors rostered every day of the week, in practice it means patients are likely to see different doctors from one day to the next. As a result, the subtle nuances in a patient’s history can slip through the cracks. When I’m picking up a patient on the acute take whom I’ve never met before, and whose last review was by a completely different doctor on a different shift, there’s a real risk that vital details get lost in translation. It’s not that electronic patient records and handovers aren’t helpful; it’s that no system can replace the familiarity and context gained from following your patients day by day.

Is this the fault of doctors? Not at all. We’re simply following the rota patterns allocated. The more fundamental issue is the design. And that design was orchestrated at the highest level by NHSE leadership, who prioritised a shiny political pledge over the realities of team-based medicine. Who were these leaders? Sir Bruce Keogh the then national medical director who was politicised for the benefit of the Government of the day. Sir Simon Stevens who enforced the imposition of this new contract dismissing the concerns raised by doctors and effectively ending negotiations. Danny Mortimer head of NHS Employers who lead the contract negotiations. Charlie Massey who was director general and advisor to Jeremy Hunt was then appointed CEO of the GMC, the doctor's regulator, and now also regulates Physician Associates.

2. The Decline in Ward-Based Teaching

Another insidious effect of these contractual and rota changes has been the steady decline in the quality of ward-based teaching. In a system that’s perennially short-staffed, it’s all too common for planned teaching sessions to be cancelled at the last minute because of service pressures. Moreover, when teaching does go ahead, it’s increasingly dedicated to what many of us would call “soft” subjects. Instead of diving into in-depth clinical topics like chronic kidney disease management, pharmacology of drugs used in parkinsons disease, or the latest use of immunological therapies in autoimmune conditions, we’re herded into sessions on “resilience” and “leadership.”

Now, I’m not suggesting that resilience or leadership are entirely without merit. Doctors do need to know how to manage stress, work with teams, and navigate complicated interpersonal dynamics. However, the pendulum has swung so far in the direction of these generic sessions that we’re missing out on the bread-and-butter clinical teachings that are vital to our competence. It is through competence and confidence that doctors will feel more resilient in the face of overwhelming sick patients. Ward-based teaching has always been one of the best ways to learn because it’s relevant, patient-centred, and practical. But the reality is that consultants are under such immense pressure to clear wards, handle overflowing clinics, and meet targets that there’s little time to do comprehensive bedside teaching for residents. The ward round becomes a fragmented task and finish rush rather than a learning opportunity.

This is a shared experience up and down the entire country which can only be ascribed to national directive and another example of NHSE’s leadership pushing for throughput without properly considering the knock-on effects. They’ll issue edicts and guidelines about the importance of leadership and resilience, but they fail to protect time and resources for the fundamental clinical teaching that’s crucial for safe patient care. If you think things are bad now, you're in for a shock in 5-10 years time when standards will plummet even faster. Read this thread on the doctor's reddit – we are now in the ludicrous position where serious and time critical interventions like chest drains are just not being taught to doctors with many expecting not to learn the skill even by the time they are consultants.

3. The Disruptive Nature of Rotational Training

One of the toughest aspects of training in the NHS – especially as a resident doctor – is the constant rotation between different departments, hospitals, or trusts. Typically, you might rotate every 4, 6, or 12 months, depending on your training pathway. The logic behind this system is superficial in theory: by rotating, resident doctors can gain a wide range of experiences and specialities, broadening their skill sets and understanding of medicine. However, the disruption this causes in team cohesion, patient care, and even mundane organisational processes can’t be overstated.

Every time a doctor moves to a new rotation, they face a steep learning curve:

• Getting to know a whole new set of colleagues, from consultants and registrars down to nurses, ward clerks, and healthcare assistants. It is commonplace for entire teams to never even learn the names of each other. If you can't even be bothered to learn the name of each other, can you imagine how bothered you are to teach them the skills necessary to develop?

• Learning the physical layout of the new hospital, which can be labyrinthine. (There’s nothing quite like being bleary-eyed at 3am and utterly lost between wards because a sign for “Ward 14B” was missing.)

• Discovering the local policies and protocols, which vary surprisingly even within the same trust. One hospital might require you to book emergency theatre slots (CEPOD) via an online form, another might insist you bleep the on-call anaesthetist, and sometimes it's left unsaid who is responsible for liaising with a theatre manager which you can imagine causes operational chaos.

This lack of standardisation across trusts and even across departments within the same trust can lead to delays in patient care. In an ideal world, there’d be national policies with clear, uniform guidelines on how to do something as critical as arranging an urgent theatre slot. Instead, you have local idiosyncrasies that waste time and can put patients at risk.

As if that weren’t bad enough, rotational training also means that just as you start to gel with your team, you’re whisked away to another department. The result is a perpetual sense of upheaval and less invested team dynamics. Strong teams depend on trust and familiarity – intangible qualities that build over time. By forcing doctors to move on before that trust can fully cement, we end up with a series of disjointed groups that never quite learn to function at their best.

The British Medical Association (BMA) have frequently and consistently asked for better training to make more efficient and productive doctors and this includes the infamous 2008 vote where they lobbied to cap the intake of students and ban new medical schools from opening. The more cynical commentators often cite this as typical protectonism to limit supply but the sensible arguments are there for all to see and indeed are being proven today by the mass doctor unemployment. The BMA has consistently asked for improvements, whether that’s prioritising clinical teaching, better induction processes, or uniform protocols across trusts. But the evidence is clear that the decision making and leadership of NHS England has been in direct conflict with the consultants who used to lead services and the experiences of resident doctors and look where that has brought us but more importantly I'll show you where this is about to take us.

4. Strikes, the Annual Winter Crisis, Morale and Retention

Every winter, we hear about the NHS being on the brink. We see photos of patients stuck on trolleys in corridors, wait times rocketing, and discharges delayed. For some reason, NHSE leadership will seize on the nearest explanation that absolves them of responsibility as if Winter is an unpredictable event. NHS England's Chris Hopson blamed increased demand on flu and covid in 2023 rather than identifying the issues on capacity and providing solutions. Recently, they’ve pointed their fingers at strike action, implying that the workforce’s decision to withdraw labour was unreasonable and triggered the crisis, as if they were unaware of the year on year results of the National NHS Staff Survey showing only 69% think their immediate manager works together to come to a shared understanding of problems, 54% were satisfied with the recognition they get for good work, 33% felt that their work was valued, 31% were satisfied with pay, 51% felt involved in deciding on changes, 55% feel able to make improvements happen, 50% were confident that their organisation would address their concerns, and 46% feel able to meet the demands put on them.

But if you compare the timeline, these crises occur year after year, well before any mention of industrial action. Even in 2025, which saw no major strikes at crucial junctures, we had a winter crisis that rivalled previous years. The pattern is clear: The absolute number of GPs has fallen by 12% in the last 14 years, the bottlenecks in A&E, the lack of social care support for step-down discharges, and the chronic underinvestment in infrastructure don’t spontaneously emerge because of a few strike days. They are structural and longstanding.

Strikes, as disruptive as they may appear from the outside, are a symptom of deeper dysfunction, not the root cause. Doctors and other healthcare workers don’t strike lightly. They do so because they’ve exhausted other avenues for achieving safe staffing levels, fair pay, and workable conditions that ultimately serve patients better. Yet NHSE’s leadership often opts to frame these strikes as reckless or as the singular culprit for all that ails the NHS, rather than confront the uncomfortable truth that the system’s design is fundamentally flawed.

The NHS Long term workforce plan retention section produces a fascinating rabbit hole that says an awful lot but does almost nothing. It talks about the "NHS People Promise" and links to "Retention hub: Looking after our people" which links to "Improving staff retention: a guide for line managers and employers" which links to this toolkit which in the "application" slide for examples to use the first link doesn't work, the second link is behind a pay wall, the third link cycles back round to policy-speake rather than concrete examples. Essentially it all boils down to, listen to your staff and be compassionate. But that is never translated into reality because there are no real examples of how to do this for managers and there is a culture set by the leaders of NHS England to not listen to their staff but to protect the reputation and integrity of the brand the "NHS".

5. NHSE Leadership’s Silence on Real Issues and Diversionary Tactics

The most galling aspect of NHSE’s leadership, in my opinion, is how selective they can be with their activism. When a crisis is unfolding every winter in our hospitals, with staff stretched beyond capacity and patients receiving suboptimal care, we often hear very little from the top ranks. The National Medical Director and other high-profile figures often provide generic soundbites urging staff to “pull together” or promising to “review the data.”

Yet, when it comes to the policies they actively promote and the paper trail leads squarely to their feet which are under criticism by doctors en masse sounding the alarm bell, they suddenly find their voice. A recent example is the coordinated response to a poorly written article in The Times, which criticised the debate around physician associates (PAs) and how toxic it had become on social media. NHS England’s leadership jumped on this, issuing statements about the need for civility and respect in debate. Here you can see the National Medical Director at NHSE Steven Powis's post on X and Chief Workforce officer Navina Evans' post on X. Both posts are filled with responses from the public and doctors alike pulling apart the article in The Times and providing evidence and context that is conveniently left out.

Let’s be clear: civility is important. No one wants a rancorous, abusive conversation dominating professional circles. However, there’s a glaring problem here. The underlying issue with the deployment of PAs isn’t whether doctors are being polite enough in their discussions; it’s that these professionals, as they currently stand, are comparatively undertrained, and are being used as a substitute for fully qualified doctors in some settings. This can undermine the quality of care that patients receive and places an unfair burden on the PAs themselves, who aren’t equipped with the same level of clinical experience as doctors yet are expected to shoulder significant responsibilities.

The fact that NHSE leadership coordinated a rapid response to defend the introduction of PAs, but remains conspicuously reticent on the core complaints behind ongoing winter crises or the eroding quality of training, speaks volumes about their priorities. Rather than addressing the legitimate concerns – which range from the safety implications of substituting doctors with less trained staff, to how this shift might exacerbate existing staffing shortages by diluting the workforce structure – they focus on condemning the “toxic debate.” It’s an exercise in misdirection that doesn’t solve any of the real problems. The whole experiment of associate professionals is laced with outrageous lies, deceptions, and espionage which continues to incite the medical profession. For example, there was a request on 20th November 2023 for an extraordinary general meeting of the Royal College of Physicians to debate and revalaute the role of PAs after it was discovered that PAs had been misleading colleagues and patients about their role, thousands of illegal prescriptions had been written, and mass amounts of ionising radiation requests had been made against the law. The EGM was supposed to happen within 8 weeks as per the rules of the Royal College however it actually occurred on 13th March 2025, conveniently after a parliamentary debate scheduled on 17th January 2024. In attendance Professor Steven Powis, National Medical Director, who has no elected role in the RCP, was offered the opportunity to answer questions directly by the chair, then president Dr Sarah Clarke who had to subsequently resign in disgrace. It has since come out that NHS England national leaders coordinated a series of communications and press releases around the delayed RCP events in order to influence the debate abusing their positions of power rather than their equal positions as Fellows of the Royal College. Most egregiously though was the presentation of the survey data that was so misrepresented and skewed that it lead to the resignation of the registrar.

For those of you who want to see the EGM, it was recorded and posted on youtube here. If you do choose to watch it, ask yourself is this the toxic debate that is being painted?

6. Physician Associates: A Symptom of a Larger Workforce Problem

The introduction of PAs into the NHS could have been a boon if done thoughtfully. There’s undoubtedly a role for physician associates to complement medical teams, helping with tasks that free up doctors for more complex work. Indeed both the BMA and the RCP have published scopes of practice that doctors are asking for help with. Instead, we’re seeing trust after trust recruiting PAs to plug the gaps in rotas whilst simultaneously NHSE Leadership say "PAs are not a substitute for doctors". NHS England leadership has got itself wrapped up in its own lies saying one thing but demonstrably doing another. When the leadership lie like this and can't be honest about issues, solutions, and strategies, they will never ever be able to deliver positive outcomes. A policy that can't stand up to scrutiny and has to be obscured by lies is not a policy worth having. But it's not just the NHSE leadership, it's also the previous DHSC advisor to Jeremy Hunt, now CEO of the GMC, Charlie Massey who is in a tangle. Originally the GMC said it would be for the Royal Colleges to set scope but then once they had, they backtracked over concerns that PAs wouldn't be employed. The regulator of course not being an employer but an institution that should be upholding standards. It is difficult to conclude anything else but that the regulator has been captured by political and institutional interests in pursuing the PA agenda.

The answer is depressingly simple. Doctors have been leaving the NHS in droves, driven away by burnout, inadequate pay progression, punishing working conditions, and a training structure that’s chaotic and lacking in continuity. Rather than honestly confronting these failings, NHSE’s leadership has decided it’s simpler and cheaper to introduce a new cadre of staff in direct conflict with doctors' roles. Again, from the vantage point of a spreadsheet, you can see how it might look like a smart solution. But from the vantage point of a ward, it’s a short-sighted fix that could jeopardise patient safety and further demoralise doctors who see their roles being devalued.

7. Where Does Responsibility Lie?

In many respects, the Government is ultimately accountable for setting budgets, national policy, and legislation around healthcare. So there’s no denying that the Secretary of State for Health and Social Care and the Treasury have crucial roles to play. However, NHSE’s leadership doesn’t get to shirk its share of the blame. They are the ones tasked with executing policy, drafting the frameworks for trusts to follow, and implementing changes to contracts, rotas, and workforce planning. When doctors complain en masse about unsafe staffing or the decimation of continuity of care, the leadership could – if they had the will – use their influence to advocate for meaningful reforms. Afterall, any effective policy needs buy-in from the people on the ground who will be the ones implementing and delivering it.

Unfortunately, we’ve seen time and again how NHSE’s leadership has either stayed silent or offered only cosmetic tweaks. Consider the following:

• Continued rota gaps: Instead of genuinely negotiating the working patterns in the 2016 contract to ensure safer staffing, NHSE imposed the contract and allowed many trusts to rely on goodwill from exhausted staff and forcibly stab them in the back denying doctors leave for life changing events like weddings or even exams necessary for career progression.

• Inadequate teaching support: They issue edicts about needing more “in-situ simulation” and “interprofessional learning,” yet do little to ease the service pressures that crowd out teaching time.

• Deflection on strikes: NHSE leaders could have taken the lead in addressing staff concerns at an early stage, potentially averting strike action. Instead, they focus on public messaging that frames staff as obstructive. Multiple times the Government refused to come to the negotiation table and yet NHS leaders kept blaming both sides.

• Neglecting structural issues: From the disjointed rotation system to the glaring lack of standardisation across trusts, these are the sorts of large-scale organisational problems that national leadership could work to standardise or improve. But we continue to languish under disparate policies that cause daily inefficiencies.

8. The Human Cost

It’s important to remember that these leadership decisions have a very real human cost. When continuity of care breaks down, patients suffer. They might have to retell their stories multiple times, or experience delays in investigations. Sometimes, an important piece of information about their past medical history or social circumstances might not get passed along properly.

For doctors, the impact is just as profound. Our training suffers when ward-based clinical teaching is repeatedly cancelled or consultants don't feel invested in training resident doctors because they'll move on shortly. Our morale takes a hit when we’re constantly rotating, never staying long enough to form lasting relationships with our colleagues, or to see the fruits of our work with patients through to the end. Burnout escalates when the system feels more like an assembly line than a place of compassion and learning.

I’ve seen colleagues break down in tears at the end of gruelling shifts, convinced they’re failing because no one actually cares about them. They feel completely isolated, undervalued, and the system is designed to literally replace them in a matter of months all while they're dealing with death and life changing illnesses for the patients they care for. I’ve witnessed promising resident doctors question whether they should continue in the NHS at all, or pursue a career abroad where their labour is valued and their training supported. Each time someone hands in their notice or takes a break from training, it’s a small but significant crack in the foundation of our health service.

9. What Needs to Happen

If we genuinely want to address the problems in the NHS, we need to look squarely at the decisions coming from inside and at the top of NHS England itself. Here are a few suggestions that have been floated time and again by frontline staff and professional bodies, but have yet to be seriously tackled:

1. Revisit the 2016 Contract: Evaluate whether the purported benefits of spreading doctors more thinly have truly materialised. If they haven’t – and there’s mounting evidence they haven’t – revert or modify the contract to allow for better continuity of care.

2. Protect Ward-Based Teaching: Mandate and enforce policies that guarantee ring-fenced time for clinically focused teaching. Rebuild the team philosophy so that doctors are cared for by other staff. This must be recognised as service provision and an investment in more confident and competent staff who will be more proficient at treating patients in the future.

3. Improve Rotational Structures: Whilst rotating can provide some value, it shouldn’t be so frequent or so poorly planned that it undermines team cohesion and patient care. Standardise certain protocols across trusts to minimise the chaos of adjusting to new systems every few months. Finally bring in this fabled NHS passport that captures mandatory learning on which colour fire extinguisher should be used.

4. Address Workforce Retention: Instead of relying on quick fixes like PAs to fill gaps, double down on retaining qualified doctors by actually teaching them, increase the number of training posts and jobs available for career progression, competitive remuneration, and genuine psychological support from the consultants that they work with that goes beyond a token “resilience” workshop provided by some HR manager you'll never see again.

5. Clarify the Role of Physician Associates: If PAs are to be integrated into the NHS, they must have a well-defined scope of practice and adequate supervision. They should supplement, not replace, doctors. Listen to the doctors and use the BMA and RCP documents which are what are asking for help with.

6. Transparency and Accountability: NHSE leaders need to be transparent about the impact of their policies and be willing to share data openly. They should invite scrutiny of outcomes, rather than hiding behind carefully curated public statements that gloss over systemic failures. The public also need to take an interest in the individuals who are actually driving and implementing the policies that are leading to the failure of the NHS rather than solely blaming politicians.

10. Looking Ahead

We’re at a crossroads for the NHS. As each year goes by, the pressures intensify, more staff leave, and public satisfaction declines. The blame game becomes more fraught, and those in senior leadership sometimes appear more invested in protecting their reputations than in rectifying the root causes of these problems. Reforming the culture requires the right people with the right incentives and disincentives in the right place and we don't have any of those things because the leadership either doesn't have the political courage to be honest and be scrutinised, policy expertise to create a more productive framework, or operational abilities to deliver the kind of compassionate environment they apparently desire.

Yet, the NHS still has an extraordinary, dedicated workforce. Resident doctors, consultants, nurses, allied health professionals, support staff, and managers on the ground care deeply about their patients and about delivering high-quality care. They’ve proven this time and again, braving pandemics, winter pressures, and political upheavals. What they need, and what patients deserve, is senior leadership that has the courage to admit mistakes, reverse damaging policies, and engage honestly with those on the front lines to give them the tools they need.

If we want an NHS that’s fit for the next 75 years, we need to confront the elephant in the room: the senior leadership in NHSE must be held to account for decisions that have fundamentally altered the structure of medical work, eroded continuity of care, and diminished the training environment. We can’t keep plastering over the cracks and blaming crises on predictable demand, pretend that introducing physician associates will magically fill the void left by experienced doctor, nor giving the NHS more money when there are clear and obvious reforms that can improve working conditions and productivity.

True leadership isn’t about writing an article defending your chosen policies or issuing press releases in lockstep using contradictory terms like "dependent… but can also work independently" when the national conversation turns inconvenient. It’s about listening to feedback from the trenches, taking responsibility for missteps, and fighting for the resources and policy changes that will sustain both staff wellbeing and patient outcomes in the long run.

Final Thoughts

I know a rant on Reddit might not change the world overnight, but all too often conversations about the NHS boil down to "it needs more money" or "it's a black hole for money" or "privatisation" or "too many managers". I hope this post can spark a more specific conversation about some specific examples of the kinds of things that are going wrong and some solutions that could help as well as highlighting some of the irritating and frustrating circular logic that managers use. Many of us genuinely want to stay in the NHS and make it work. We believe in the principles of a healthcare system free at the point of need. But unless those at the top start owning up to their role in the slow-motion collapse we’re witnessing, it’s hard to be optimistic.

If you’re reading this and you’re part of that senior leadership, I challenge you to set aside the spin and politics, to step out onto the wards and clinics more regularly, and to speak with staff at every level. Hear what they’re saying about rotas, continuity of care, training, and workforce gaps. Acknowledge how poorly some of these initiatives – especially the 2016 contract changes – have served patients and staff. Re-read The Tooke Report and "The Role of The Doctor" – most of us agree with that definition so equip us with the tools, actually build strong teams that stay and grow together in the spirit of excellence, and reap the dividends of a happy workforce. Then, and only then, can we begin to rebuild a system that actually lives up to the ideals upon which the NHS was founded.

Until that day comes, we’ll keep calling out the problems and hoping that, somewhere in the corridors of NHSE’s headquarters, someone is listening and willing to do something different. Because if we allow the current trajectory to continue, we risk losing the heart of the NHS altogether: the dedication and expertise of those who work within it, and the trust of those who depend upon its care.