Intended for healthcare professionals

Editor's Choice

A hesitation to be brave

BMJ 2009; 339 doi: (Published 27 August 2009) Cite this as: BMJ 2009;339:b3468
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    No one doubts that there’s going to be less money for health in the next few years. But is this a disaster or, as John Appleby believes (doi:10.1136/bmj.b2736), a potential opportunity? Taking his cue from White House chief of staff Rahm Emanuel, Appleby says we can’t let this economic crisis go to waste. It would be too easy to slash budgets, grow waiting lists, cut training, and reduce spending on prevention just to store up problems for the future. Instead we should “get radical with improving quality,” he says. “Doing the right thing for patients the first time can not only improve the quality of their care but save money too.”

    This idea that quality is cheaper in the long run is the latest wisdom in Whitehall, but acting on it isn’t going to be easy. Appleby fears that we (doctors, managers, politicians) won’t have it in us to be radical enough. So we should listen to Carl May and colleagues’ prescription for “minimally disruptive medicine” (doi:10.1136/bmj.b2803). Instead of focusing on the burden of illness for the health system, they want us to consider the burden of treatment for the patient. In one case, a man with heart failure had paid 54 visits to specialist clinics over two years, the equivalent of one whole day every fortnight. Not unreasonably he was refusing further specialist help. In another case, an elderly woman was unable to care for herself at home because she was trying to take medications on 11 separate occasions through the day. The disconnected doctors involved in her care had no idea what each was asking of her.

    Unless we redesign the way we manage chronic disease, say the authors, we will continue to see poor adherence, wasted resources, and bad outcomes. We need to coordinate care better. We need evidence based guidance on how to manage conditions that commonly co-exist, like diabetes and heart disease. And above all we need to allow patients with complex chronic comorbidities to decide for themselves which problems they want to tackle next and how.

    We’re clearly still a long way from what Don Berwick of the Institute of Health Care Improvement sees as our proper destination: where those who offer health care “stop acting like hosts to patients and their families and start acting like guests in their lives” (’s%20Top%20Ten%20Tips.pdf). Kieran Sweeney, a professor of primary care, is dying of mesothelioma. His moving account shows how far we still have to go (doi:10.1136/bmj.b2862). He asks health professionals to stop saying “Do this for me.” “I’m not doing it for them, I’m doing it for me,” he says. And he describes the technical competence of senior clinical staff being undermined by “a hesitation to be brave.” It’s a strange phrase, but it captures the reluctance to share or even acknowledge a patient’s journey into the lonely realms beyond hope.


    Cite this as: BMJ 2009;339:b3468

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