Intended for healthcare professionals

Editor's Choice

While Rome burns

BMJ 2006; 333 doi: (Published 21 September 2006) Cite this as: BMJ 2006;333:0-f
  1. Fiona Godlee, editor (fgodlee{at}

    Something strange is happening in the NHS. I don't mean the chaos of constant policy change, the threat of closures, the job losses, the financial crises—we are used to all that. No, I mean that although the service functions and patients are seen and treated, many of them satisfactorily, something important is quietly dying. I don't think it is too fanciful to call it the spirit of medical professionalism. And we, the medical profession, are watching it die.

    We asked Nigel Hawkes, an experienced health journalist, to give us his take on the NHS reforms (p 645). The result was unexpected. He describes a breathtaking ride through the past 15 years and concludes that, far from being privatised, medicine in England has become ever more a creature of the state. From the scrapping of the internal market in the early 1990s; through the NHS Plan in 2000; to the recent reinvention of the internal market; all that has really changed, he says, is who does the kicking and who is kicked. Increasingly centralised decision making, driven by a political imperative for constant reform, has left us victim to “a patchwork of mutually contradictory ideas struggling for dominance.”

    You can see the appeal of centralised decision making, but it leaves no scope for regional experimentation and diffusion of best practice. And although medicine has embraced the need for evidence based medicine, policy making remains largely an evidence-free zone. Hawkes voices the policy makers' justification: if health reforms needed proving before they were tried, nothing would ever get done. But even some evidence would be a start. In his personal view (p 661), Richard Lehman decries the lack of debate about the proposed hospital closures announced by the NHS's new chief executive last week (p 617). It is, he says “the personal responsibility of our professional leadership to mark out where the evidence lies, what it says, and what it is lacking.”

    But where is our leadership? And where, asks Ian Greener, are the voices raised in protest against the breakdown of Aneuran Bevan's founding concordat: that the government would fund the health service but leave its operational running to the doctors (p 660). “The government has found ways to interfere in medical practice on a remarkable scale,” he writes. In the absence of coherent protest we might conclude that doctors have once more had their mouths stuffed with gold or that the medical profession wholeheartedly approves of the government's reforms. However, the most likely reason is more worrying still, as Greener agrees: that most doctors no longer have the will or power to stop the reforms.

    If the government isn't listening, can the medical profession make it listen? We must, if our professional integrity is to be salvaged. Whether through established bodies (the BMA, the colleges, the large medical institutions) or through non-aligned groups led by inspired mavericks (the Cochrane Collaboration might serve as a model), the message to policy makers must be “stop, consult, and look at the evidence.”