Contracts excluded the patient's voice and lacked an intellectual overview

It is said that behind every disagreement there are the bones of an old philosophy rattling around. Surveying the wreckage of the consultants' contract,1 and seeing also that the general practitioners' contract2^–4 is floundering in heavy seas—such that even if it is rescued5 it will start life half drowned—has made us wonder what has gone wrong with the process of making contracts for doctors. We want to look deeper, to open out more fundamental debate about what medicine could and should be for, and so what should and should not be in doctors' contracts.

Doctors and managers historically have prided themselves on their pragmatism rather than their philosophy. Getting the task done has been more important than asking whether the task is valid in the first place. To the negotiators from the BMA, the Department of Health, and the NHS Confederation, setting out in 2001 to draw up a contract will therefore have seemed a sensible and achievable task, whereas debating the …