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Letters Quality of care economics

The blind leading the disempowered

BMJ 2009; 339 doi: (Published 05 October 2009) Cite this as: BMJ 2009;339:b4067
  1. Peter J Mahaffey, consultant surgeon1
  1. 1Bedford Hospital, Bedford MK42 9DJ
  1. peter.mahaffey{at}

    Senior jobbing clinicians running their day to day services are best placed to identify cost issues and the sources of clinical failings. But their voices are rarely heard. They feel disempowered, swept along on a sea of management directives, protocols, primary care trust demands, short staffing, European Working Time Directive constraints, and much more. To preserve their sanity they keep their heads down and survive under fire as best as they can rather than apply the intellect which made them consultants. Moreover, they go home as fast as possible to the comfort of the family environment, whereas 25 years ago the NHS was effectively their family.

    Those responsible for the massive distractions to clinical care—politicians, administrators, and management consultants—don’t want to accept any of these factors as causes because it was they who instituted them.

    Appleby wonders about addressing the problem by “providers bearing the costs.”1 We’ve all shrugged our shoulders at the daily nonsensical threats of fines being administered on one part of the NHS by another. Isn’t it time to consider carrots rather than sticks? He says, “saving money is not a prime motivating factor for clinicians.” But it is in the private sector, where we are conscious every day of the uninsured status of increasing numbers of our patients.

    Only when Appleby and his ilk become aware that their philosophising is the problem and not the cure will we return to productive and efficient secondary medical care. Just give us a proper voice for once.


    Cite this as: BMJ 2009;339:b4067


    • Competing interests: PJM is a bread and butter working consultant.


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