Until now medical schools have had it easy. They have lots of high quality applicants, most students graduate, and all of them can find jobs. Suddenly, as for many others in Britain, the world looks more hostile.

I hang around medical schools, and many people think it likely that one or two medical schools may close in the next 10 years. The country may well not be able to afford the number of doctors set to graduate in the next decade, and the NHS may be increasingly interested in cheaper alternatives like physician assistants and nurse practitioners. Medical unemployment may be close.

And if unemployment becomes a reality then potential students may be more reluctant to take on the increased debt that will be the result of lifting the cap on tuition fees. At the very least students paying large fees may become more discerning customers and turn away from schools that don’t offer a rich experience and a high likelihood that they will be well regarded by future employers and so be able to get the jobs they want. In other words, competition among schools will increase—and the competition may be on quality and price. And some may go the wall.

 So as a dean how might you ensure that your medical school will survive and flourish? The general answer is easy: like any business you must delight your customers and offer value for money. But who are the customers? Essentially there are two: students and future employers of doctors. What is it they want?

Employers, essentially the NHS in Britain, want doctors who are clinically competent, patient centered, empathetic, good communicators, team players, and ethical.  But that’s the minimum (even though it’s not always achieved). What might be the extra factor, the USP (unique selling point) of a graduate? I believe that it’s the capacity to understand, work in, and even enjoy a complex system (all hospitals) and to be able to contribute to improving it. That sounds pompous, and it could be just a capacity to enjoy change—but I think that it’s more, not least it’s a knowledge of the crunchy complexities of improvement science. And I think that this could be the right extra factor because I hear so many leaders of hospitals complain that doctors are more part of the problem than part of the solution.

And what do students want? I’m tempted to say “minimal hassle in the transition from schoolchild to doctor,” but it must be more than that. Might it be the capacity to flourish within a complex environment? So might it be that students and employers want the same thing?