We often look to policy, structure, or technology to fix the NHS.
But what if the real answer lies in something much closer to home, the moment a clinician and a person make a decision together?
In this episode, Dr Johnny Marshall explores why clinical decision making shapes outcomes, costs, and experience more than anything else, and why improving the quality of those conversations may be the most important step towards a safe and sustainable NHS.
Transcript
Introduction: The Heart of the NHS
Today, we’re diving into a theme championed by Professor Al Mulley: the importance of clinical decision-making and why it still sits at the heart of a safe, sustainable NHS. For decades, the NHS has wrestled with how to balance quality, efficiency, and equity. We’ve seen endless reforms, structures, incentives, targets. But as Al Mully reminds us, the real health system lives in the moment a clinician and a person make a decision together. That decision about investigation, treatment, or whether to act at all determines more of the system’s outcomes, costs, and experience than almost anything done in Whitehall or the boardroom.
The Problem: Variation and the Silent Misdiagnosis
Mully’s central argument is simple. Variation in clinical practice reflects variation in decision-making. And when that variation isn’t grounded in people’s preferences or good evidence, it drives waste, harm, and inequality. He calls this the silent misdiagnosis. Not of disease, but of what matters to people. When we fail to diagnose people’s goals, values, and tolerance of risk, we make decisions about them rather than with them.
So it’s not just clinical skill. It’s about relational skill, listening, eliciting preferences, weighing trade-offs, and sharing power. By giving people space to talk and for us to listen, we generate new intelligence, which helps us to make better decisions.
Clinical Decision-Making as Stewardship
In a resource-constrained NHS, clinical decision-making isn’t a soft skill. It’s the ultimate act of stewardship. Every referral, test, or prescription allocates finite NHS resources. The question isn’t just is it clinically possible, but is it necessary, valuable, and aligned with what this person really wants? So why does it matter now? The NHS is under extraordinary strain, waiting lists, workforce shortages, financial pressures. It’s tempting to think that the answer lies in new technology or organizational reform.
But as Mully points out, the biggest determinant of value sits in the consultation room, not the boardroom, with the decision making. And most of those decisions are made upstream in primary care.
From Variation to Value
AI decision support pathways and protocols can help, but they must support clinical judgment, not replace it. When we overstandardize, we risk stripping care of meaning and professional purpose. And when clinicians lose agency, the system loses wisdom. We need to move from variation to value. Mully’s work at Dartmouth helped pioneer the choosing wisely movement, encouraging clinicians and patients to question interventions that add little value or may cause harm.
Simply doing those interventions more productively causes very little benefit. We need to work out how to stop doing them at all. But he also cautions against assuming that less is always better. The goal isn’t to ration, it’s to match care to what matters. That’s how we deliver what he calls preference sensitive care rather than supply sensitive care. It requires understanding of what’s important to them, to listen before you act to increase the intelligence on which you’re making a decision, and to have trust and relationship between person and doctor.So there’s time to consider all of the options and choose the most appropriate one rather than simply the most biomedical one.
Implementing Shared Decision-Making in the NHS
In the NHS, that means embedding shared decision-making into every pathway, giving clinicians time, data and confidence to say, let’s pause. What outcome are you hoping for? Well, the implications for the NHS is if we’re serious about population health, the lesson from Al-Mully is clear. We need to see clinical decision-making as both an individual and collective act of leadership. That means training clinicians not just to interpret data, but to navigate uncertainty with people. Designing systems that measure value, not volume. Creating cultures when doing less when it’s right is seen as professional wisdom, not failure. And clinicians have the time and the trust to explain this to people. And giving teams the digital, analytical, and emotional infrastructure to make better decisions together.
Conclusion: Reclaiming the Art and Science of Medicine
It’s about reclaiming the art and science of medicine, guided by evidence grounded in empathy. Clinical decision making is where medicine meets meaning. If we want the NHS to thrive, we have to invest not just in new technology, but in the conversations that decide when and whether to use it. You’ve been listening to Neighborhood Health Conversations. If you enjoyed today’s episode, please share it and join the debate on how we can restore trust, value, and humanity to healthcare, one decision at a time.
