In common with many other health systems internationally, the U.K. National Health Service (NHS) is in a sorry state. Specialties are stretched, most beyond the point of elasticity. Many have snapped and are broken.
It is not just a case of left-wing rabble-rousing or doctors having a good old moan. NHS and healthcare understaffing is completely genuine. Workload has grown as the populace lives longer and gets frailer and as healthcare grows in complexity. Funding has either been cut in real terms or never reaches the front line. Productivity has dropped as the NHS becomes more difficult to work in.
How have we coped?
We cope by working harder. Too hard, in actual fact. This has resulted in an epidemic of burnout and general miserableness. We cope by making desperate attempts to boost productivity. But as soon as you cut through some red tape, more seems to grow back, like a fairy-tale magic forest.
We cope by employing additional staff. Ideally, we employ new consultants, residents, fellows, and associate specialists. But they are expensive and a rare commodity. Increasingly, we employ other practitioners to pick up the slack: specialist nurses, physician associates, and an increasing number of assorted therapists. When we are really stuck, we employ locums. But they are very expensive and of -- erm -- variable quality.
The problem is fairly simple: It’s a three-decade-long mismatch between growth in CT/MRI (about 8% per year) and workforce growth (about 4%). Other aspects of radiology have grown, but they are sideshows to the massive increase in cross-sectional imaging, particularly “out-of-hours” or emergency radiology, which has been growing at over 10%-20% annually.
Nothing has changed in U.K. medical practice this century more than out-of-hours radiology. Nothing comes close. Twenty years ago, radiology departmental shutters came down at 5 p.m., and getting a scan after that was close to impossible -- unless there were, for example, votive sacrifices. Now, the shutters never close. Residents don’t even have to write request cards with their own blood anymore.
The Royal College of Radiologists has pointed out this staffing crisis for over 25 years, and it has been spot on in its predictions. The shortfall in consultant radiologists is currently 30% -- about 2,000 consultants short. One wag summed up the whole debacle: “NHS workforce planning is an oxymoron.”
Increasing radiology reporting capacity is difficult. We’ve tried to recruit. We’ve tried to retain. We’ve tried to insource. We’ve tried locums. But still, the workload outstrips demand. Not only is there a rising demand and an inadequate workforce but also increasing expectations. It is a perfect storm. It is also perfectly depressing. My beautiful specialty is on its collective knees.
Reliance on teleradiology
Increasingly, the answer is outsourcing to teleradiology companies. Hence, the maxim of “all roads lead to outsourcing.” This feels like an admission of defeat. Rare are the radiologists who want to give away their work.
We are very aware of the optics. Resorting to outsourcing looks like local radiologists either just don’t care or are too lazy. Or both. But I can assure you that the very opposite is true. Radiologists absolutely do care. Most have an old-school work ethic and will work themselves to the bone, fully aware that their altruism is being exploited.
Without private outsourcing, most U.K. radiology departments would be completely devastated. Ninety-five percent of U.K. hospitals now outsource at least some of their radiology. Without outsourcing, scan reporting delays would spiral off into the distance. Delays of weeks would become months. This then causes the rest of the hospital to seize up. Radiology reporting delays cause patient harm in many direct and indirect ways.
Outsourced radiology is way more expensive than in-house reporting. The NHS has spent over £1 billion (€1.1 billion) on outsourced radiology in the last decade. In 2024, the NHS spent over £200 million (€230 million) on outsourcing, £29 million (€24 million) on locums, and £80 million (€92 million) on insourcing, representing a 16% increase since 2023. Of note, this £325 million (€374 million) would pay for the salaries of 3,000 consultant radiologists, one third more than the current shortfall. This annual spend is forecast to grow to £550 million (€633 million) in the next five years.
Anyone with a modicum of common sense or financial know-how would look at this spiraling outsourcing bill and whistle through their teeth. It is obviously much cheaper to train more radiologists and therefore fill vacant existing posts, but NHS higher management rarely plans anything beyond the financial year-end. And I can tell you that training is absolutely the last consideration.
There are advantages to outsourcing radiology. It is flexible, ramping up or down as necessary. Difficult service delivery niches can be filled. And if you pay more, scans can be hot-reported on a 24/7 basis, which keeps out-of-hours radiology service provision alive in the U.K. Overall, the companies offer a safe and valued service.
However, there is an elephant in the room. Every surgeon and every physician that I know hates outsourced radiology reports. It isn’t new; teleradiologists have been getting a kicking for decades. There is even a word for it: “telebullying.” I’ve no personal axe to grind myself. Some of my best friends are teleradiologists.
Bad reputation
So why do teleradiology reports have such a bad reputation?
I have some theories here. I don’t think that teleradiologists are any worse than their local counterparts; they are all U.K.-trained and registered consultant radiologists. I don’t think it is because they rush their reports due to time pressures; this is the same for all radiologists. I don’t think it is because they are younger, more inexperienced, or less trained; there are plenty of very senior radiologists working as teleradiologists.
But I have noticed that the problem lies with younger teleradiologists. They commit two cardinal sins of radiology reporting. First, they overcall like crazy, littering their reports with extraneous findings of dubious provenance. Second, they hedge like crazy, seemingly unable or unwilling to ascribe significance or lack of significance to their doom-laden reports.
These are the hallmarks of defensive practice. It stinks because the surgeon doesn’t know what to do with the report -- are the findings real or spurious? So, a local opinion is sought, which creates work for the local radiologists -- the very opposite of what was intended. But the frequency of such defensive reports tars all teleradiologists with the same brush. Which isn’t fair, as the majority are fine.
So what to do?
The answer is simple in my mind. Overcalls and unnecessary hedging need to be viewed in the same way as missing a key finding. False positives are just as much of an error as false negatives. I’m not calling for fence-sitting teleradiologists to be beaten with their own shoes. Well, not too hard. And only briefly. I think that you just need to deduct a proportion of their reporting fee for each misdemeanor. Every overcall, all unwarranted hedges, and every unnecessary vague statement leads to a 25% deduction of their fee. That’d certainly focus their attention. Certain miscreants would end up with a net loss. The problem of the poor teleradiology report would dry up overnight.
Editor’s note: This article was first published on 11 February 2026 by BJS Academy as a part of Paul McCoubrie's "view from the dark side” series.
Dr. Paul McCoubrie is a consultant radiologist at Southmead Hospital in Bristol, U.K. Competing interests: None declared.
His latest book -- "More Rules of Radiology" -- is available via its publisher, Springer, as well as local bookstores ( ISBN-13 978-3031640933).
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