Medicine's Uncomfortable Truth: Is Avoiding Money Talk Is Making Things Worse?
Show Me the Incentives, I'll Show You the Outcomes
As I dig deeper into the business of healthcare, theres one question that keeps coming up… would medicine actually work better if doctors owned more of it?
It sounds obvious in theory. Who better to run a healthcare business than the people doing the actual healthcare? But the reality, at least on both sides of the Atlantic, is that medicine has quietly drifted away from doctor ownership, and most of us barely noticed it happening. Partly because we were too busy. And partly because, as a profession, we’ve never been particularly comfortable talking about money.
That discomfort is costing us more than we realise.
In the US, the numbers tell the story plainly. Back in the 1990s, somewhere between 60 and 75% of physicians were self-employed. Today, that figure has collapsed to around 30 to 40%, with hospital systems, private equity firms, and insurers absorbing what used to be independent practices. When private equity really leaned in around 2017, particularly in dermatology, anaesthesiology, and emergency medicine, the model became familiar: acquire the practice, pay the founding doctors a lump sum, lock them into a three to five-year contract, then shift the metrics toward productivity and profit. The doctors who stayed on became employees. Younger ones joining never had the option of ownership at all.
The UK got there differently, but ended up in a similar place. GPs technically operate as independent contractors to the NHS, but the funding model, contract constraints, and bureaucratic weight mean that clinical autonomy has become something of a polite fiction. Hospital consultants have even less say. You’re operating within a system largely designed without you, and often despite you. In 2026, there seems to be a new shift towards reducing the amount of doctors and even replacing them with Advanced Clinical Practioners, even more of an example where doctors have less say.
And here’s the thing. Show me the incentives, and I’ll show you the outcomes.
When doctors aren’t owners, the KPIs of the business stop reflecting the actual goals of medicine. This is why I am very bullish on this series generally, most healthcare decisions boil back to being business decisions. Patient outcomes become secondary to throughput. Prevention gets deprioritised because it doesn’t generate activity. Nobody sat down and decided this was the goal. It’s just what happens when the people closest to the patient have no stake in how the organisation performs. If you want to understand why the profession’s values, continuity of care, patient-centred decisions, clinical integrity, keep getting eroded, follow the ownership structure. The values of any institution tend to reflect the values of the people running it. Fewer doctors at the ownership table means fewer doctors shaping what the institution actually optimises for. Or one could argue is the instiution even optimising for what doctors would want to be optimising for? Is it about High Quality Care or High Output Care?
This is why the cultural allergy to money talk in medicine is such a problem. I strongly believe the advice most UK doctors get about ‘Don’t worry about the money until you’re a consultant’ is terrible advice. It gets dressed up as professionalism, as though being above financial considerations is somehow noble. But it isn’t noble. It’s naive. And it’s left the profession increasingly unable to protect itself. When pay disputes come up, when contract negotiations happen, when health systems restructure, doctors who have no ownership stake, no equity, no financial literacy built into how they think about their careers, find themselves with very little leverage. You can’t advocate effectively for the profession from a purely employed position when the people across the table have spent years thinking about nothing but the economics.
The counterargument to all of this is real though. Running a practice is hard. The admin, the compliance, the HR, not knowing how much you’ll make. It’s a full-time job layered on top of an already full-time job. The NHS absorbs a lot of that friction, and not everyone wants to be an entrepreneur. Fair enough I totally get it.
But we’ve overcorrected. We’ve let “this is complicated” become “don’t bother.” The more doctors are told that ownership is too hard, too risky, too much, the more ground we lose. And we’ve been losing ground on it for decades. As much as everyone can’t and shouldn’t be an entrepreneur, we shouldn’t be discouraging the ones that do because they can fly the flag for the values of the profession. In the same way not everyone can be a surgeon, but those who do should be championed
My view is that ownership should be something the profession actively pushes toward. Not every doctor needs to run a practice, but more of us should be thinking about it, trained for it, and encouraged toward it, because the doctors who do own have an outsized voice on behalf of everyone who doesn’t. They’re in the rooms where decisions get made. They sit on boards, shape contracts, and push back on the metrics that everyone else just has to live with. This is the same in other sectors; the people who own the businesses on the high street have a strong hold on outcomes for the local community because they have financial power.
Ownership doesn’t only exist in the entrepreneurial capacity it also exists as intrapreneurs. Doctors should be actively encouraging each other to take on board roles within the hospital or local department. You will find in the majority of hospitals, there is no doctor on the board, even as a Non-Exec Director.
Medicine has always prided itself on its values. But values don’t sustain themselves. They need to be defended by people with the power to defend them. Right now, we’re handing that power away and calling it simplicity.
Articles
https://www.ucl.ac.uk/news/2024/sep/20-fall-gp-surgeries-while-patient-lists-grow