This House believes doctors are neglecting their duty to lead health service change: Proposer

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1578 (Published 21 April 2009) Cite this as: BMJ 2009;338:b1578
  1. Alan Maynard, professor of health economics, Department of Health Sciences, University of York
  1. akm3{at}york.ac.uk

    At worst the doctor should do the patient no harm. At best they should practice EBM—in this case, economics based medicine—by focusing on the comparative cost effectiveness of competing interventions.1 EBM requires doctors to recognise the universal issue of opportunity cost, where a decision to treat one patient involves the denial of treatment to another patient. It also obliges the doctor to focus on value: the value of what they give up when they treat a patient (cost) and the value of what is gained as a result of treatment—hopefully improved length and quality of life for the patient. Clinical practice should be driven by the pursuit of EBM, conditioned by humane consideration of the patient’s needs, particularly at the end of life.

    From Barbara Castle in 19762 to Ara Darzi in 2008,3 there has been political and policy focus on variations in clinical practice and a failure by the profession to acknowledge these problems and practice safe, conservative evidence based medicine. Consequently patients with similar characteristics and needs receive very different packages of care. This is a ubiquitous international problem, with evidence from the United States that improved practice could produce better care and save 20-30% of the budget.4

    Healthcare systems are not underfunded. They are profligate. The failure to translate evidence and policy advocacy into improved care has wasted resources and deprived patients of care from which they could benefit. Such inefficiency is unethical and prima facia evidence for deregistration of medical practitioners.

    So why have doctors failed to translate evidence into practice? Clinicians practice in isolation rather than corporately. They hide behind media induced blame of “management” for clinical failures, as epitomised by the problems in Mid Staffordshire Trust. The quality of patient care is largely determined by doctors and their clinical colleagues. Any “failure” to deliver good quality care to patients is a product of management, both clinical and non-clinical. When clinicians and hospital “fail” clinical leadership, as exemplified in Bristol and elsewhere, has proved to be sadly inadequate.

    The failure of clinicians to demand and use comparative data facilitates the maintenance of poor practice. Their often fierce herd protection of colleagues ensures that non-clinical managers proceed too meekly in collaboratively exploring and mitigating practice variations to protect the frequently defenceless consumer.

    As we stumble from recession into depression, the public finances cannot afford large increases in NHS funding. The demand for care is increasing due to demography and marginal improvements in the cost effectiveness of some medical technologies. Without a quantum shift in collaborative clinical leadership, the NHS will fail to provide adequate patient care. Consequently, care will become even more fragmented than it is now as the affluent exit the NHS and leave the poor and elderly to their lot.

    Physicians, heal thyselves, and take the NHS into the EBM Promised Land advocated by Archie Cochrane5 and other significant leaders of your profession.


    Cite this as: BMJ 2009;338:b1578



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