Hi @FraserNelson!

Thanks for being one of the few journalists to try to understand what is REALLY happening with medical training in the UK.

It's a complicated topic and I commend you for being mostly right in your exposition.

A few points:
1/
thetimes.com/comment/column… 1. Doctors pay has been eroded more than any other group in the UK. Neither I nor the residents are worth 30% less than we were in 2009.

So it is quite right for the BMA to fight for pay restoration.
2/

Discussing the 'skill escalator' concept with Martin McKee (late of this parish). Mentioned in the 10YP.

This suggests that anyone entering the NHS workforce can 'progress' through different roles/grades, limited only by their 'potential'.

It has been touted as a partial
1/ solution to workforce problems and as an engine for 'social mobility'.

What this means in practice is this:
Enter NHS as a HCA ➡️ Diploma ➡️ NA apprenticeship ➡️ NA ➡️ Top-up BA ➡️ RN ➡️ Masters ➡️ ACP ➡️ Work as a doctor

No need even for GCSEs, let alone systematic study of
2/

Hi Iain,

I just found this longer thread. Thanks for engaging an honest appraisal.

As someone who has been doing research on acute/emergency care for a 15 yrs, let me tell you how and why my views have shifted on this topic.
1/

https://twitter.com/docib/status/1978353332075810950

I fully acknowledge the workforce problems with not just EM, but across the piece. Yes, it is an international problem post-Covid.

But this has been a crisis a long time in the making.

I first came across 'alternative' workforce solutions in EM back in 2013/14, when
2/

This thread created a bit of a stir.

But as one of the few doctors trained in HoM, I think it's important to elaborate WHY I think this type of 'research' is such a problem.

A thread on HoM. 🧵

https://twitter.com/Dr_Done_/status/1974011461812019707

Academic HoM is NOTHING like what most doctors are familiar with - the 1 page fillers with interesting snippets or the 30 seconds at the start of a talk.

It also isn't anything like History as taught in schools or on TV.

HoM has been increasingly dominated
2/

Here is an example of what is coming.

The whole of Medicine, broken down into tasks and tiers.

No need for knowledge. No need for expertise.

Brought to you by HEE.

Lets take a look at the new(ish) Framework for Asthma (May 2025).🧵
1/ Outcomes for young people with asthma in the UK are pretty rubbish.

So the framework is a response to a legitimate concern.
2/

If anyone wonders how workforce substitution happened in UK, how people didn't notice, one only has to look to what is happening currently in Australia.

Here is the recently released report on doctors' working arrangements in Victoria:

1/ health.vic.gov.au/sites/default/… There is LOTS of good stuff in this. Directly addresses real issues around pay, contracts, careers and bullying.

BUT buried in the fine print are 2 paragraphs.

The first recommends workforce substitution by ANPs and other members of the MDT. To help doctors.
2/

Just off the Leng Review call.

Once again it strikes me just how existential the issue of workforce substitution is and what is at stake.

The root cause is not enough doctors. Historically, not enough in rural and remote places. With the coming 'Silver Tsunami', not enough
1/ anywhere in the world. Except perhaps Germany.

The logical solution is train more doctors and to use carrots (+ the occasional stick). But this is expensive!

So the alternative, since the 1960s, has been workforce substitution. This is attractive, as it certainly is true
2/

Apopros of the thread below, I took a look at the NHS Plan (A Plan for Investment. A Plan for Reform) of 2000.

This is a critically important document. One could argue that most of what are faced with now wrt workforce can be traced directly back to it.

A few highlights. 🧵
1/

https://twitter.com/DrLKVaughan/status/1900166668849959178

The problem formulation is eerily familiar.
2/

The origins of the PA project have intrigued me.

The conventional narrative is that various plucky heroes went off to the USA and were impressed by what they saw there with regard to PAs, AAs, SCPs etc. Brought the model home and persuaded others that it was A Good Thing.
1/ This was picked up by the Blair/Brown Govt as part of their reforms of public services more generally and the NHS in particular.

The Royal Colleges were supposedly a bit late to the party, but enthusiastic from mid-2010s.

Well, I have just been the rabbit hole this morning!
2/

Events unfolding in Australia re PAs and workforce substitution.

Brace yourself for a tumble down the rabbit hole! 🧵

https://twitter.com/UQHealth/status/1895247750712766475

Last year, @qldhealth laid the groundwork for the expansion of PAs in Queensland.

Frameworks were put in place that would allow PAs to prescribe + order ionising radiation despite NOT being recognised by the super-regulator APHRA.



2/health.qld.gov.au/__data/assets/…

A take from Someone Who Was There about the PA Project.

FWIW, @mancunianmedic is mostly right. But I disagree with him on a few points (natch!).
🧵
1/

https://twitter.com/mancunianmedic/status/1815270278848520331

1. Workforce substitution within the professions was/is an explicit plank of Blair/Brownite reforms to make public services cheaper and (coughs) the professions more tractable.

The first PAs were brought over from the USA in the early 2000s as part of this.
2/

Because I am a woman of my word, here is a look at GMC Colin's blog about proposed changes to UG and PG medical training.

It is a tough gig, as it is unhappy reading.

1/ gmcuk.wordpress.com/2024/03/12/dev…

https://twitter.com/DrLKVaughan/status/1770071398498644446

Starts with a preamble about changes to medical practice.

Usual stuff about demographic change. Older, more complex pt population with complex needs.

The really points to a solution that involves more Generalism. I thought was what Shape of Training was about? 🧐

Because the RCP is a large, complex and rather opaque organisation, here is a thread about how it is organised and functions.

And some of the ramifications that the current goings-on are shedding light on.

So buckle up punters, for a Vaughan mega-nerd 🪡
1/ At the most basic level, the RCP has a government-style structure.

A leadership team (some elected, some appointed), an elected Council and then various Committees. This is the doctor-facing bit most familiar to the profession.
2/

There has been lots of discussion about Scope of Practice recently.

I spent several months trying to understand concepts of scope and regulation for a piece of funded research.

So here is a bit about what I learnt.
1/ Scope can be 'set' in several ways.
1. By custom and practice
2. Through legal precedent (the Courts)
3. Via training and assessment of competence
4. Explicit limitation as set out in law, standards etc.

As a rule of thumb, the older the profession, the more likely
2/

As a clinician, I am only dimly aware of the built environment of the hospital. And usually only when annoyed (door/lift/sink rage).

3 days at the European Health Property Network workshop opened my eyes to a few things.

🧵of interesting snippets.
1/ Firstly, there are phalanxes of people who DO care about the built environment - architects, engineers, academic, manufacturers, estates people.

They are all deeply dedicated to health care. Just in a different way.

I salute them all!
2/

The world's largest experiment in the delivery of Emergency and Acute Care has been quietly happening in Denmark.

Massive reconfig of ALL acute care.

The European Health Property Network meeting this week informally assessed the outcomes.
🧵
1/ The Danish Super Hospital programme is ambitious.

Closure of HALF of all hospitals. Reorganisation of care within hospitals. Reconfig of admin.

PLUS 6 new hospitals. 10 refurbs/extensions. Cost E5Bn or so.
sum.dk/Media/0/2/TheD…
2/

Continuing my occasional series on cities post-Covid.

This time: Copenhagen!

Which has fared better than anywhere else visited so far.
1/ Things are pretty normal. Hard to tell there has been a pandemic.

A few shops are closed. But it look like retail churn rather than economic wipe-out.
2/

@gmcuk is proposing that the primary ‘duty’ of a doctor should to ‘Be Kind’.

Sounds nice right? Kind doctors are a good thing.

A thread on why I think this is a problem,
1/ As a hospital consultant, much of my job involves things that are not ‘nice’, but are essential to running a fair and equitable service that has limited resources.

An example. Pt asks to stay over the WE as their family is away. There are no beds and pts waiting >24hrs
2/

Hospitals are unsafe at the weekend! Not enough doctors!

Finally, definitively, shown to be NOT true.

A short thread about the key findings from the (long awaited) HiSLAC study.

journalslibrary.nihr.ac.uk/hsdr/hsdr09130…

1/ Patients admitted on weekends are sicker and frailer, with a suggestion that present to hospital because they are unable to access other types of care.

So it is differences in CASE-MIX that drives the weekend effect.

2/

Nearly everyone is changing their patterns of working, thanks to #COVID19.

So there is an opportunity to move away from 12hr shifts towards better working based on evidence.

Here are some thoughts on how shift systems can be structured to support better wellbeing.

1/x The evidence is unequivocal that 12 hr night shifts are BAD.

Use correlates with:
- poorer sleep
- more burnout
- lower morale
- more errors
- people leaving

See work by @ora_dall @workforcesoton @LindaAiken_Penn

2/x