Money is the problem. Money is the solution.
The NHS is a socialist healthcare system rooted in universal access, free at the point of need, functioning inside a capitalist economy. The tension between these two forces has played out for 76 years. Nowhere is it more visible than in the consultant contract.
The compromise that built the NHS
The birth of the NHS was resisted by the doctors. Medicine was financially rewarding, and socialism was not in the financial interests of the hospital doctors. The compromise: consultants could continue private practice alongside their secure NHS salary. A dual system. Public work as NHS doctor with the right to build private practice in the evenings, weekends, and part-time sessions. That model has survived, with minor tweaks, for 76 years.
The contractual relationship rested on the consultant being a professional, trusted to do the job. The annual job planning meeting was a cursory nod to the idea that the NHS was buying a quantity of programmed activity. In reality, the meetings were brief, the documents rarely enforced, and the understanding was vague.
The 2004 New Contract aimed to change that. The socialist employer wanted value for money. What it really aimed to suppress was hidden private practice eating into NHS provision without the NHS being able to charge for the opportunity cost. The effort to turn consultants into programmed activity producers made for a very expensive contract. Two decades later, job planning remains, for most trusts, a work of fiction.
The variation nobody measures
At STRASYS, the Decision Intelligence engine for healthcare, we see the variation through the Consultant Workforce Optimisation System. It is considerable.
In the same department, one consultant does two theatre lists a week and sees twenty clinic patients a month. Another does eight theatre lists and sees eighty patients. Same pay. Same contract.
In the same service, one consultant completes four procedures per theatre session. Another completes eight. Same programmed activity. Same payment.
There is a consultant who has negotiated a full-time 10 PA contract that he delivers over three days a week. He spends weekdays in private practice and weekends on his hobbies. The employer has failed to manage the contract.
This three-day full-timer illustrates several truths: the NHS consultant post matters for prestige. The prestige is a gateway to building private practice. The NHS waiting lists are a source for that practice. The NHS post provides secure income and a good pension. None of this is wrong. It is how the contract is constructed, as though every consultant from Barts to Blackpool is not a professional with finite time, finite energy, and finite integrity.
Capitalism papers over the cracks
For 76 years, the socialist system has used capitalism to get out of its holes. The NHS bought out the doctors resisting the new service in 1948, with money. It bought private hospital capacity during Covid. It bought new hospitals through PFI contracts, making the capitalists rich while the socialist employer paid double the build cost. It buys insourced and outsourced capacity from private providers to deal with waiting lists, delivered by people who work a little faster because they do not have the same broken culture.
An endoscopy insourced service provider works over two days and accounts for over 50% of one NHS unit's workload. An ophthalmology provider over two days accounts for 40% of another. One dermatologist gave up his NHS job to see NHS patients through private provider contracts, getting paid more than when he was an NHS consultant.
The weakness of the socialist system, unable to motivate its workforce and unable to manage its talent, has been papered over with money spent on buying capacity from those who can.
CWOS exists to make this visible. It triangulates clinical activity, job plan data, and financial performance to reveal where the trapped value sits, where PA variation is costing the trust, and where the same money could produce more care if the contract were properly managed through team-level optimisation.
Naeem Younis, STRASYS CEO, argues that the consultant contract is not broken because consultants are lazy. It is broken because nobody has built the decision infrastructure to manage it. The data to reveal the variation, the framework to have the conversation, and the team-level job plan that connects consultant deployment to population need. That is what CWOS provides.