Right now there is a trust in deep financial trouble because of its emergency department. Over two thirds of its operating expenditure flows into all things ED: the cost of acute admissions, the cost of dragging specialists in from the rest of the building, the cost of a department that never stops consuming. ED income is capped, so the trust haemorrhages cash. Less than a fifth of the operating expenditure goes on elective care. Elective work earns income. The more elective work done, the more income earned. Instead, money is being thrown at the ED problem, and performance gets worse.
It is not the only trust in this trap.
The strike that proved the point
The Financial Times reported this week what every NHS leader already knew but few would say on the record. For the first time, a number of NHS leaders admitted to several truths about the ED model. Some would only speak anonymously.
Nick Hulme, recently retired as chief executive of East Suffolk and North Essex NHS Foundation Trust, went on the record. Another hospital boss confirmed that A&E works so much better during a strike because having senior decision-makers at all points through the hospital means you do not admit people who do not need to be admitted. Two more health officials confirmed to the FT that it was widely accepted that emergency departments ran more smoothly during strikes.
The December 2025 junior training resident doctor strike was managed differently. Trusts achieved great ED performance alongside delivering more elective work. Over 92% of elective care was maintained. The JTR doctors were not missed by the patients.
What happens during every strike: ED waiting rooms empty. Four-hour targets met. Corridors clear of patients. Transfers to inpatient beds happen easily because there are plenty of beds. Ward patients are safe. Undignified deaths in corridors are avoided.
The common factor: consultants at the front door. The most experienced decision-makers in the building, making the call on who needs admission, who needs redirection, who needs discharge. Not juniors learning on the job, escalating upward through layers of variable decision-making.
Flip the model
At STRASYS, the Decision Intelligence engine for healthcare, we have been making this argument through data. The Consultant Workforce Optimisation System exists because the evidence from every strike demonstrates the same principle: when consultants are deployed at the point of greatest clinical impact, the system produces better outcomes at lower cost.
The escape route: analyse ED demand through a consumer needs lens. Reimagine the models of care and allocate experienced senior decision-making consultants to those needs. Use job planning demand analysis of elective and acute needs, and the financial impact data, to develop a value-focused language and a common purpose.
Imagine 26 cardiologists in a trust working not just as a team in clinics, cath labs, and on wards, but also as part of the ED team. Not to see the snake bite or the stroke patient. The patient with cardiac needs who does not need a junior generalist making uncertain decisions. Map the right type of consultant to the types of patient need presenting at the front door.
The NHSE response was a brand new "model emergency department" to roll out. Four years later, there is no sign of it.
The consultant contract moment
The BMA has started setting out demands for the next round of consultant pay negotiations. The ask: less direct clinical care. A four-day week. Trusts are steadily working out how to refocus consultant job plans. This is the moment to redesign.
Welcome to the trust. Your consultant contract describes responsibilities that include being rostered for on-call, ward work, outpatient clinics, and ED. The job plan, although technically yours, is in fact a team and organisational job plan that ensures capacity and expertise are optimised to meet all points where patients enter the building seeking care.
No more money. No more staff. No more anything. The money is there. The consultants are there. Just misallocated. It will take exceptional leadership and courage. To flip the NHS ED crisis.
Workforce Decision Intelligence provides the analytical infrastructure to make this operational: connecting consultant deployment to patient demand patterns, revealing where senior decision-making capacity is trapped in low-value activity, and quantifying the financial impact of reallocation.
Naeem Younis, STRASYS CEO, argues that the ED crisis will not be solved by more staff, more money, or more national plans. It will be solved by putting the right decision-maker in front of the right patient at the right time. The strikes prove this works. The question is whether the NHS has the courage to make the temporary permanent.