Intended for healthcare professionals

Opinion Taking Stock

Rammya Mathew: The NHS and its staff are being set up to fail

BMJ 2022; 379 doi: (Published 29 November 2022) Cite this as: BMJ 2022;379:o2863
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

When I chose to become a doctor all those years ago, I never imagined that my career would take this path: being a GP, but also spending a significant proportion of my working week immersed in medical management. It wasn’t on my list of ambitions to be a medical director. My early career was devoid of role models in medical management, and if I’m honest, I was naive to much of the responsibility that came with the role—that is, until I started doing the job. So, on the one hand, it’s curious that this is where my career path has taken me.

On the other hand, I’ve always passionately believed in building fair and compassionate workplaces for healthcare staff, recognising and valuing people for the work they do. It matters a lot to me that all healthcare staff are supported and developed, that their views are heard and given credence, and that they’re not just at the receiving end of decisions made at an organisational level that make no sense to them. So, perhaps my career has taken me to where I’m meant to be after all.

But it’s by no means an easy job. Just as our clinical work can feel like daily firefighting, it’s much the same in medical management. The current workforce crisis in particular leaves me with no shortage of problems, many of which I feel powerless to solve. Although I’m personally committed to creating a positive workplace culture and environment for my teams, I can’t help anyone thrive in the face of severe understaffing. Workload pressures take their toll, patients don’t get the service they deserve, and this eats away at morale. The fallout from this is that staff leave or reduce their hours, leaving an even bigger problem to fix.

Add to this the pension debacle, whereby doctors can end up paying to go to work if they increase their NHS commitments to plug gaps, and it’s no wonder I’m not exactly inundated with offers of taking on extra paid NHS work from existing staff. And market forces have led to an exponential rise in locum rates—all factors which, in combination, have led to a situation where we’re disincentivising continued commitment to core NHS work, making it more attractive to work on a locum basis or leave the NHS altogether.

Watching this situation unfold and being caught in the crossfire as a medical manager is not a happy place to be. I want better for my teams and for their patients. Extra medical school places being petitioned by the royal colleges, among others, is welcome—but we need solutions that will make a difference now, not in 10 years’ time when the damage will most likely be irreversible. Solutions for the here and now are not within my gift to implement, but without them it feels as though the NHS and its staff are being set up to fail.


  • Competing interests: None.

  • Provenance and peer review: commissioned; not externally peer reviewed.