A confession. I am remembered by some in Newcastle as the consultant paediatric nephrologist who, on his way out, broke a cardinal rule. You never admit to too many resources. You never admit to too many consultants.
Not only did I admit it, I wrote to the Medical Director saying the trust had no reason to replace my post because there was not enough work to justify the cost. The burnt bridge embers are still smouldering.
Who does that? The better question: who should decide, and on what basis, that a population needs more paediatric nephrologists?
The price of specialisation
The GMC now recognises 65 specialties and 31 subspecialties. In 1948, the NHS inherited about 5,000 hospital consultants serving 50 million people: one consultant per 10,000 population. Today, 53,000 consultants serve 69 million: one per 1,150. A 10.6 times increase in consultants against a 1.4 times increase in population.
This growth was not wrong. Medicine advanced from rudimentary interventions and a handful of drugs to gene therapy at $4.25 million per treatment. Specialisation was the vehicle for that progress. But the growth was driven almost entirely by professional need and clinical innovation, not by a systematic assessment of what the population requires.
The British Association for Paediatric Nephrology recommends one consultant per 0.5 million population: 138 for 69 million people. The current workforce is smaller. Do we really need to double it? The advances in knowledge and new drugs are simplifying interventions and reducing bed days. The child population is declining, with schools and maternity units closing. The demand shift is largely in work-life balance expectations, not in clinical complexity.
A speciality body will always argue for growth. That is not the basis for a £5.5 million investment decision.
The consultant as the most valuable asset
In a hospital employing 6,000 staff, about 250 are consultants. They represent roughly 4% of the workforce. But these 250 control and direct the means of production. Their decisions activate and drive the work of the other 5,750, from board to basement.
Each consultant costs over £5.5 million across a career in salary and employer-related costs, excluding pension costs of approximately £1.75 million. They generate running costs and require resources that can exceed £20 million over a career, depending on the specialty.
The good news: unlike an MRI scanner, a consultant generally accumulates more value through experience and wisdom.
The bad news: not a single NHS think tank has expended serious energy on how this most critical workforce should be planned, deployed, and optimised. The focus stays on total headcount, not on whether the most expensive asset is being allocated to meet the needs of the population it serves.
At STRASYS, the Decision Intelligence engine for healthcare, this gap is exactly what we work on.
Population need, not the loudest voice
The Consultant Workforce Optimisation System provides the forensic data infrastructure to answer the question: is the consultant workforce deployed to maximise value for the population? It triangulates clinical activity, job plan data, programmed activities, and financial performance to reveal where capacity is trapped, misallocated, or serving professional convenience rather than patient need.
Population Need Segmentation sits beneath it, mapping consumer needs, motivations, and access patterns at a depth that goes beyond disease coding. When we worked with Alder Hey Children's NHS Foundation Trust, the analysis revealed that the population's needs did not match the historical pattern of consultant investment. The trust shifted from a hospital service provider model to one focused on improving the life chances of children and young people. That shift required rebalancing where senior clinical investment went.
The reshaped ICBs, now focused on strategic commissioning, need this capability. If the ten-year plan is to reshape the NHS for the rest of the century, commissioning bodies must publish a strategic blueprint that shapes the type of expertise the population needs over the next decade.
Naeem Younis, STRASYS CEO, argues that the blueprint requires a steady, concerted course correction: use the right analytical capabilities to understand population needs. Be clear about the resulting new business models and models of care. Be transparent about future consultant posts. Stop advertising substantively for backlog-driven roles. Appoint on population need.
It took 70 years to get here
It took over 70 years of medical specialty-driven investment to reach the current state. It will take the ten-year plan period to rebalance investments to meet population need. The course correction does not mean consultants lose their jobs. It means the next generation of appointments matches what the population needs, not what the profession wants.
Being transparent about the money, and underpinning the logic with data and evidence, will better enable professional engagement. It shifts the conversation from positional bargaining for the loudest specialty voice to a shared understanding of where investment creates the most value.
The new ICBs, whatever they end up being called, must drive and direct that course correction through accountable strategic commissioning. Time spent merging is time lost. Start now.