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When we talk about NHS administration, it often gets described as systems, processes, inefficiencies. That’s not how it feels in general practice. From where I sit as a practice manager, administration is the bit that either helps a patient get care – or quietly stops them from getting it at all, writes Kay Keane in this guest blog for The King's Fund. The recent report from The King's Fund talks about patients feeling ‘lost in the system’. What is less visible is the amount of work happening every single day to stop that from happening.  

The past decade has seen a steady movement towards expanding the roles of different healthcare professionals, including physician assistants, nurses, and pharmacists, driven by the belief that there aren’t enough doctors to cover all the work. This has given other professionals greater scope to take on tasks traditionally performed by doctors. This trend came to a head with the planned expansion of physician assistant roles, which led to pushback from doctors about how it could encroach on their roles, training, and progression. The escalation of the debate prompted the Leng review on the safety and effectiveness of physician associate roles. Seven months on from that review, the Royal College of Physicians hasn’t firmed up its interim document on scope, nor have steps been taken to stop these roles being advertised, although the adverts have declined. It feels as though everyone has ducked their responsibility to implement the review’s recommendations, writes Partha Kar in an opinion piece for the BMJ.

The Health Services Safety Investigations Body (HSSIB) has launched its new strategy ‘Building Investigation Excellence’ to help meet the demands of a changing patient safety landscape. The strategy will be instrumental in supporting investigators across the NHS to carry out high-quality investigations that drive real improvements in patient safety. The strategy will be building on the already strong track record of the current HSSIB education programme. Since 2023, more than 40,000 people have undertaken their courses, demonstrating the need for this expertise amongst healthcare professionals. Through a targeted approach, the strategy, focuses on strengthening capability in investigation skills, increasing accessibility to investigation resources, improving the professional connections between investigators and working in collaboration with the national health system to align priorities and reduce duplication. As the document outlines “the healthcare system has significant activity in patient safety investigations – what’s needed is a greater depth of expertise, stronger investigation methodology grounded in human factors, and more sophisticated system thinking.” Work on the strategy was commenced in late 2025, against the backdrop of significant healthcare announcements including the restructuring of NHS England and DHSC, and the Review of the Patient Safety Landscape which set out HSSIB’s role as a ‘centre of excellence for healthcare safety investigations. It also outlined plans for integration into CQC. The strategy was not developed in isolation. Over 250 healthcare staff and representatives from national organisations shared their views and insights via workshops, surveys and interviews. Many talked about their experiences of undertaking investigations, and the support they required. Stakeholder insights provided clear messages and strong building blocks for the future. They called for more practical support to bridge the gap between safety investigation theory and practice, to maintain and improve access to resources, and to target areas of healthcare where investigation capability gaps exist — for example, primary care and mental health, which were identified as underserved. The final strategy captures four key methods for focus: Targeted capability building – proactively direct support where the gaps in investigation capability are greatest or where it aligns with investigation priorities. For example: rather than waiting for applications for courses, HSSIB could identify sectors, organisations or cohorts of providers that would benefit from intensive support. Accessible resources – the aim with this is to ensure that alongside targeted support, HSSIB provide accessible resources, and this could look like: developing online modules, toolkits and guides, as well as signposting to other resources to increase collaboration Professional leadership – to enhance the developing field of healthcare investigation and to link up and connect investigators in the absence of a professional association. National system convening – this is aimed at co-ordinating national efforts to build the capability of healthcare investigators to reduce duplication and aligned priorities particularly in the light of healthcare restructuring. The strategy also focuses on establishing wider partnerships, noting the healthcare system already has considerable expertise, infrastructure, and established relationships.

Attentional focus narrows as individuals concentrate on tasks. Missing an event that would otherwise appear obvious is termed a perceptual error. These forms of perceptual failure are well-recognised in psychological literature, but little attention has been paid to them in medicine. Cognitive workload and expertise modulate risk, although how these factors interplay in practice is unclear. This video-based experiment was designed to explore the hypothesis that perceptual errors affect clinicians. 142 volunteers with varying levels of experience of adult resuscitation were shown a short video depicting a simulated cardiac arrest. This video included a series of change-events designed to elicit perceptual errors. The experiment was conducted on-line, with participants watching the video and then responding via combinations of open-ended free-text and directed questioning. 141 people experienced at least a single perceptual error. Even the most clinically significant event (disconnection of the patient's oxygen supply) was missed by three in four viewers. Although expertise was associated with increased likelihood of detecting an occurrence, even highly significant events were missed by up to two thirds of the most experienced observers. This study demonstrates that perceptual errors occur during healthcare-relevant scenarios at significant levels. Events such as an oxygen malfunction would meaningfully affect patient outcome and, although expertise conferred some advantages, events were still missed more often than not. Data acquisition is fundamental to good-quality situational awareness. These results suggest perceptual error may be a contributor to adverse events in practice.

In 2023, Jennifer Cahill was pregnant with her second child. Her antenatal care was managed by Manchester Foundation Trust (“MFT”) community midwives. In 2021 her first pregnancy had resulted in complications at the time of delivery. She had a Post Partum Haemorrhage for which she received an iron and also a blood transfusion. She was also positive for Group B Streptococcal. On the 26 June 2024 an investigation into the deaths of Jennifer and Agnes Cahill was carried out. The Inquests concluded on the 27 October 2025. The conclusion of the Inquests was: Jennifer Rose Cahill died as a result of complications arising from the delivery of her second child, contributed to by neglect. Agnes Lily Wren Cahill died as a result of complications during birth, such complications contributed to by neglect. The medical causes of death were recorded as:  Jen: 1a) Multiorgan failure with disseminated intravascular coagulation 1b) Cardiac arrest due to post-partum haemorrhage 1c) Perineal tear and atony during term delivery. Agnes: 1a Multi-organ insult following hypoxic ischaemic encephalopathy 1b. Cord compression and meconium aspiration syndrome leading to pulmonary hypertension. Key findings Jen had not made an informed decision to have a home birth and if the out of guidance plan had been completed and all the relevant information provided to her, it is more likely than not she would have given birth in an alternative setting and both Jen and Agnes would have survived. If the fetal heart rate monitoring had been conducted correctly and every 5 minutes, it was more likely than not an abnormal fetal heart rate would have been noted up to an hour before Agnes was born and an urgent transfer to hospital would have occurred. The coroner found emergency services would have been on scene when Agnes was born and effective resuscitation would have been administered which would likely have prolonged her life. Had this call been made it is more likely than not Jen would have survived as the after care delivered to her would have noted a perineal tear and administered syntemetrine immediately. The coroner heard evidence that since the deaths, MFT have completely overhauled the home birth service provision. The new service became operational in April 2025. In the six month period within the MFT area of GM they have received requests from 34 women for out of guidance home deliveries. Five of these could not be supported due to safety issues. Of the 29 out of guidance home births, 15 (50%) required transfer to hospital for varying degrees of obstetric emergency. Matter of concerns There is no national guidance in respect of home births. Specifically, robust evidenced based guidance on home birth care, similar to that which is in place for intrapartum care in a hospital setting. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death, even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low risk. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance. The no national guidance on the model of staffing, training and experience for midwives providing home birth care. See also: NHS England's letter responding the Prevention of Future Deaths report.

The Academy of Medical Educators recognises that medical education is distinct from teaching in higher education in general because of the central place that patient care occupies not only in teaching and learning but also in assessment and feedback, and in quality assurance. Its Professional Standards framework makes explicit the values, skills, knowledge, and practical capabilities required of those engaged in medical education and has been developed in wide consultation with the international community of professional medical educators. This framework identifies five practice domains. Each domain contains detailed descriptions of elements, outlining the expected understanding, skills and capabilities. These detailed outcomes describe and underpin expert professional practice in medical education. Each element within these domains is sub divided into four levels which represent increasing levels of capability, competence and responsibility.

We know the NHS is facing a workforce crisis, but how many people work in the NHS in England, what roles are they in and are they happy with their jobs? The NHS workforce is growing, but demand for care is also rising and health needs are increasingly complex. While headlines often focus on overall staff shortages, the reality is more nuanced as highlighted in this King's Fund analysis of the NHS workforce.

This diagnostic report sets out the current state of medical training and identifies 11 recommendations, including four key priorities: making training more flexible, building on excellence beyond formal routes, addressing damaging bottlenecks, and rebuilding inclusive team structures where doctors feel valued. While the report acknowledges risks and trade-offs in implementing major changes, it concludes that the gap between current practice and future needs is significant enough to justify action. Recommendations We recommend that a reform of postgraduate medical education and training is undertaken as a matter of urgency. Addressing bottlenecks at all points in training and development should be considered urgently. This will have to include consideration of the right ratio between new international graduate entrants to medicine in the UK and those who are already working and training in the NHS, taking into account the workforce need. Training should become more flexible. All doctors working in the NHS should be supported to progress and the differentiation between ‘training’ and ‘service’ roles should be made less rigid for doctors early in their careers. We recognise, however, that progression will not be at the same rate for all doctors. The output from the review of rotational structures must be incorporated in the wider reforms. Reform of medical training must consider the need to provide a medical workforce across the country for the whole population equitably. This means changes in medical school places and training places should take account of where medical need is growing and will grow in the future; this is seldom wealthy metropolitan areas. We recognise that there is a tension between this need and the geographical preferences stated by resident doctors. A strategy to deliver educators who are supported and enabled to train the future medical workforce in a fit for purpose environment and with transparent funding should be a fundamental part of NHS reform. Training reform should aim to make the role of the educator less rather than more bureaucratic. Resident doctors training in craft and procedure heavy specialties must have time to develop procedural skills, particularly early in their training. This includes requiring the independent sector to provide training if the NHS is commissioning and paying for the procedures it undertakes. We should work with the other UK nations to support the GMC’s review of standards and outcomes and subsequent review by colleges of postgraduate training curricula, including considering changes from the 10 Year Health Plan. This will include maintaining generalist skills while specialising; and ensuring digital skills for all doctors, which are essential for future patient care. The recruitment to medical training should be reviewed to ensure it supports future models of training delivery and training flexibility and is fair and equitable to all candidates, while aiming to recognise excellence in medical practice. Clinical academic medicine is essential for the delivery of healthcare now and in the future, both in academic centres and across the NHS. This workforce should be developed to meet the current and future population health needs, particularly in primary care, community and public health settings.

On 11 July 2023, Susan Evans underwent elective Roux-en-Y gastric bypass surgery. The surgery went to plan and appropriate measures were taken to avoid the possibility of an anastomotic leak, a rare but recognised complication of gastric bypass surgery. Initially, Ms Evans recovered well, but she experienced abdominal pain in the early hours of 13 July 2023. It is likely that this was due to an anastomotic leak. 13 July 2023 was the first day of a junior doctors’ strike. Unrelated to this, the hospital only had the equivalent of one full time specialist bariatric nurse, who was not on duty. Contrary to Queen Alexandra hospital’s written policy for gastric bypass patients, Ms Evans was not seen by a member of the specialist bariatric team on 13 July 2023 and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak. The hospital at night nursing team, who administered pain relief, were unaware of the latter requirement. In addition, Ms Evans not seen by a member of the bariatric team or any doctor prior to her discharge from hospital on the morning of 13 July 2023. Ms Evans was still in a degree of pain when she left hospital. She was re-admitted to hospital on 15 July 2023. By this point she was extremely unwell with abdominal sepsis from an anastomotic leak. She underwent remedial surgery on 15 July 2023 and a further operation was required on 25 July 2023. Despite appropriate medical care following her re-admission, her condition deteriorated, and she died at Queen Alexandra Hospital on 12 August 2023. It is likely that, if she had been seen by a member of the bariatric team on 13 July 2023, she would have been kept in hospital and would have been operated upon sooner. The failures identified contributed more than minimally to her death. Matters of concern Queen Alexandra’s written post operative care pathway for patients who have undergone a gastric bypass operation states that: There is to be a daily review by a bariatric specialist nurse, consultant or registrar. A senior doctor is to review within 2 hours if there is increased abdominal pain in order to rule out anastomotic leak or bleed. In addition to this, the inquest heard evidence that patients should be seen by a member of the specialist bariatric team prior to discharge. This is not included in the written policy. Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day 2 after surgery and the pain she experienced from the early hours of 13 July 2023 was not escalated to a senior doctor at all. The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain. The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern.

The Royal College of Physicians (RCP) has published new interim guidance on the scope, supervision and employment of physician associates (PAs) working in the medical specialties (also known as the physician specialties).  The interim guidance covers scope of practice for general internal medicine, supervision and employment of PAs, and how PAs should describe their role to patients, employers, other healthcare professionals and the public. It will be reviewed in collaboration with stakeholders, including RCP fellows and members, following the publication of the report of the Leng review. In the guidance, the RCP is clear that: PAs must support – not replace – doctors, have a nationally defined ceiling of practice, and have a clearly defined role in the multidisciplinary team (MDT). PAs must never function as a senior decision maker, nor should they decide whether a patient is admitted or discharged from hospital. Resident doctors are not, and must not be expected or asked to be, responsible for the clinical supervision of PAs. PAs should only be supervised by consultants, specialist or associate specialist doctors. PAs cannot prescribe medications regardless of any prior healthcare background while working as a PA. PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors, and provide details of their educational and clinical supervision when required.

Right Care, Right Person (RCRP) is an approach that is aimed at ensuring that people of all ages who have health and/or social care needs, are responded to by the right person, with the right skills, training, and experience to best meet their needs. Home Office and Department of Health and Social Care (DHSC) analysts evaluated the implementation of RCRP through a rapid process evaluation covering police, fire, health and social care services. The findings highlighted the importance of communication, openness and transparency across agencies when implementing RCRP. While generally supportive of RCRP principles, participants highlighted some implementation challenges, such as capacity limitations for health and social care services. Early data monitoring showed a reduction of police time spent on health-related incidents post RCRP implementation. Recommendations to support the implementation of RCRP are included.

Upcoming regulation will hold physician associates and anaesthesia associates to higher standards, ensuring safer patient care and stronger accountability while addressing doctors’ concerns on team integration; however, there is still more to be which requires our collective energy to find solutions that deliver for all those who work in our health services, and ultimately for all those who rely on them for their care.