Change may occur by diktat, evolution, or default. So how did we move from a “consultant led” to a “consultant provided” service? Has anybody thought through the consequences? When I first entered medicine hospital doctors often did not become consultants, particularly in surgical specialties, until they were well into their 40s. In true Lancelot Spratt style consultants then had an impressive retinue: senior and junior registrars, senior house officers, and—in one instance I can remember—a “first assistant.”

Doctors often preferred treatment by senior registrars for themselves or their families because they were usually the most up to date and had the most immediate hands-on experience. They were certainly experienced practitioners with a great deal of independence. Unfortunately they were still called “junior” doctors.

The system ensured that the burden of on-call work finally passed, so that when a doctor finally became a consultant he (it usually was a he in those days) could be consulted about difficult cases, which he then had the time to deal with because he did not …