Here is the rule. You get one change. Not a reform programme, not a ten-year strategy, not a white paper. One thing that could, in principle, be switched on tomorrow morning in the system where you work. It can be a rule, a form, a payment, a habit, a piece of software, a meeting you would abolish.
The constraint is the point. Ask health professionals what is wrong with healthcare and you get a list that never ends. Ask them for one change and you find out what they actually believe matters most.
To get the conversation started, we have written a few example answers below. To be clear, these are hypothetical. They are not quotes and they are not attributed to anyone real. They are composites of the kinds of arguments we hear often, written deliberately to provoke. Disagree with them. That is what they are for.
Example 1: A hospital nurse would abolish duplicate documentation
“I would make it impossible for any system to ask me for information another system already holds. Today I record a patient’s allergies on admission, again on the drug chart, again on the handover sheet and again when they transfer wards. Every copy is another chance to get it wrong. Every minute spent typing is a minute not at the bedside. I do not need a new app. I need to stop being the cable between four computers.”
The strength of this answer is that it costs nothing clinically and attacks something everyone hates. The weakness is that “tomorrow” is doing a lot of work. Interoperability is the change everyone agrees on and nobody delivers.
Example 2: A GP would pay for time, not visits
“I would change what a consultation is worth. At the moment a ten-minute visit about a sore throat and a ten-minute visit with a frail patient on twelve medicines count the same. So the system quietly encourages me to see more simple problems and fewer complex ones. Pay me for the time complex patients actually need and you will see fewer of them in the emergency department.”
Provocative because it asks for more money for primary care, which every GP would say. The honest counter is that paying for time invites longer appointments without better outcomes, and measuring complexity fairly is harder than it sounds.
Example 3: A hospital manager would publish every waiting list, by consultant
“I would make every waiting list public at the level of the individual team, updated weekly. Not the national averages we hide behind. The real queue, with names on it. Sunlight would do more to change behaviour than any target I have ever been given.”
This one tends to split rooms. Supporters say transparency changes behaviour faster than regulation. Critics say it punishes teams that take the hardest cases, invites gaming and shames clinicians for problems caused by bed shortages they do not control.
Example 4: A public health doctor would move one per cent of the budget
“I would take one per cent of hospital spending and move it, permanently, into prevention that pays back over ten years or more: smoking cessation, blood pressure control, childhood vaccination catch-up. Not as a pilot. As a rule written into the budget, so the next crisis cannot raid it.”
The argument is that prevention always loses to the urgent, so it needs protection. The counter-argument is that one per cent taken from hospitals already running at full stretch has real consequences next winter, and the gains from prevention arrive long after the people who made the decision have moved on.
Example 5: A junior doctor would scrap the rota as we know it
“I would give every junior doctor their rota twelve weeks in advance, and make late changes cost the employer money. Half of the burnout I see is not the hours. It is not knowing when the hours are. You cannot plan childcare, study or a life around a schedule that changes the week before.”
Small, specific, cheap in theory. Its opponents will say that service needs change at short notice and someone has to fill the gap. Its supporters will say that is exactly the problem.
Example 6: A patient advocate would give every patient their own record
“I would give every patient full, readable access to their own record, including the notes, by default. Not on request, not after three forms. People would catch errors, arrive at appointments prepared and stop repeating their history to every new face.”
The objections are familiar: clinicians worry about notes written in shorthand being misread, about safeguarding in abusive households, about extra workload answering questions. The supporters’ reply is that the record is about the patient, so the burden of proof should sit with the people who want to keep it closed.
Example 7: A pharmacist would end the repeat prescription on autopilot
“I would make every long-term prescription expire unless someone actually reviews it once a year, with the patient, and asks whether each medicine is still doing anything. We have patients on ten or fifteen drugs, some started a decade ago by a doctor they no longer see, for a reason nobody can remember. Every one of those drugs interacts with the others. Nobody owns the whole list.”
This is the kind of change that sounds administrative and turns out to be clinical. Its supporters argue it would cut side effects, falls and waste in one move. Its critics point out that reviews take time nobody has, and that a hard expiry date risks patients running out of medicines they genuinely need because the review slot was never booked. The design detail decides whether it helps or harms.
Example 8: A finance director would count the cost of delay
“I would put a price on every week a patient waits. Right now, a waiting list costs my budget nothing. The costs show up somewhere else: a worse outcome, a lost job, an emergency admission, a carer who gives up work. If the cost of delay appeared on my ledger, I would make very different decisions about where to spend.”
This answer is interesting because it comes from the person most people assume is the obstacle. It is also the hardest to implement. Delay costs are real but diffuse, they fall on many budgets at once, and estimating them invites endless argument. The underlying point is still sharp: organisations optimise for the costs they can see.
What the examples have in common
Read the eight answers together and a pattern appears. Almost none of them asks for a new technology or a large sum of money. Most target one of three things.
The first is where information goes. Duplicate documentation, closed patient records and hidden waiting lists are all about who can see what, and when. Much of the friction in health care is not about clinical knowledge. It is about information failing to travel to the person who needs it.
The second is what gets paid for or counted. Paying for time rather than visits, protecting a prevention budget and pricing delay are all attempts to change the scoreboard. People inside the system respond to what is measured and rewarded. Change the scoreboard and behaviour follows, often faster than any training programme could achieve.
The third is predictability. The junior doctor’s rota and the pharmacist’s expiring prescriptions both try to replace ad hoc decisions with a reliable rule. Unpredictability has a hidden cost: people spend energy coping with the system rather than working within it.
If your own answer falls into one of these three, you are in good company. If it falls outside them, that is interesting in itself, and we would like to hear it.
How a good change can backfire
The most useful comments on this exercise tend to come from people who have seen a sensible idea go wrong. It is worth thinking about second-order effects before you post.
Transparency can produce gaming. Publish waiting lists by team, and some teams may quietly stop accepting the hardest referrals, or reclassify patients to look better on the published measure. The sunlight still helps, but only if someone is also watching for the ways people will respond to it.
Protected budgets can harden into entitlements. A ring-fenced prevention fund is safe from raids, but it is also safe from scrutiny. Five years on, it may be funding programmes that no longer work, because protection removed the pressure to prove value.
Paying for time can reward slowness. Unless complexity is measured well, a payment for longer consultations can be claimed for simple cases too. The fix is not to abandon the idea but to pair it with an honest measure of who actually needs the extra time.
Fixed rotas can move pressure rather than remove it. If late changes cost the employer money, the employer will look for other ways to fill gaps, such as more agency staff or more pressure on the doctors who are already rostered. The change still might be worth it. But a good proposal names where the displaced pressure goes.
None of these objections means the changes are wrong. They mean a proposal is only as good as its answer to the question: once people adapt to this, what will they do?
Why one change reveals more than a wish list
There is a reason we insist on a single answer. When people list ten problems, they tend to list the same ten: funding, staffing, IT, bureaucracy and so on. The lists are accurate and almost useless, because they do not tell anyone where to begin.
Forcing a single choice reveals priorities. It shows which problem a person thinks is upstream of the others. A nurse who picks documentation is implicitly saying that time at the bedside is the binding constraint. A GP who picks payment is saying that incentives shape everything else. A patient advocate who picks record access is saying that the system underestimates what patients can do for themselves. Put enough of those choices side by side, from enough roles and countries, and you get a map of where people inside health care think the leverage is.
That map is what we are trying to build here. We will read every answer, group them by theme, and report back on where different roles agree and where they clash.
What makes a good answer
Having read many versions of this exercise, we think the best answers share three features.
- They are specific enough that you could tell whether the change had happened. “Better leadership” is not a change. “No meeting over thirty minutes without a written decision” is.
- They name who would lose. Every real change costs someone something: money, power, convenience, status. Answers that pretend otherwise are wishes, not proposals.
- They come from where the person actually stands. The most useful answers are about the corner of the system you know better than anyone else.
Your turn
Tell us your one change in the comments. Start with your role and your country, then the change in a single sentence, then why. If you think one of our examples is wrong, or dangerous, say so and say why. The most interesting threads are usually the ones where a nurse and a finance director disagree about the same problem.
One change. Tomorrow morning. What is it?
