Views And Reviews No Holds Barred

Margaret McCartney: Publishing doctors’ private earnings is not enough

BMJ 2016; 355 doi: (Published 04 October 2016) Cite this as: BMJ 2016;355:i5370
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}

The proposal to publish NHS consultants’ private earnings must have led to sharp intakes of breath all along Harley Street.1 We British are squeamish about money talk. And NHS England’s timing—right after the junior doctors’ strikes and before negotiations on the consultants’ contract—has prompted suspicion.

I was brought up in the era when consultants weren’t there to take ward rounds because they were “down at the mint” (seeing private patients). Then, also, private ambulances would deposit patients with no recordable blood pressure into NHS care. These were patients freshly wounded by private institutions that lacked intensive care facilities. Without doubt, there has been disgraceful misuse and abuse of the NHS while the private sector drank tea in china cups and washed its hands of such indelicate, unprofitable situations.

Recent guidance from NHS England makes it clear that some doctors with two employers have a conflict of interest so great that it is impossible for them to fulfil both roles.2 But subjective judgments on inevitable fuzziness will not necessarily improve anything. Who should decide, for example, whether a doctor can work as a consultant or an adviser to an industry that seeks business with the NHS? The head of an NHS department, an outsider to industry, may lack awareness of what knowledge can be gained or exploited, or what relationships are created and levered, and for whose current and future gain.

Openness is important, and I agree that all our earnings should be published. But there is much else that the public should know. How much do postgraduate education, exams, indemnity, and membership fees cost? How many unpaid hours do staff work beyond their contract? What improvements and savings do NHS staff make, in their own time and for no personal profit? And how much stress and sick leave are caused by known poor working conditions? Answers would give meaning beyond simple transparency.

The savings the private sector makes at cost to the NHS should be published too—and maybe even charged for. The detail of contracts the private sector holds with the NHS deserves scrutiny (and this may happen if the new UK information commissioner has her way3). How much does the private sector save by having access to a stream of ready trained, appraised, and revalidated doctors?

Transparency can only ever take us so far. Though we can never be rid of all potential conflicts of interest, be they religious, political, or philosophical, we should ensure that unnecessary financial conflicts are stymied. The Health and Social Care Act has created many potential conflicts through GPs commissioning their own services, for example, and influence over local prescribing decisions has been exploited.4 Publishing doctors’ earnings is not enough; we need to be rid of the structures that create conflicts.

There has been disgraceful misuse and abuse of the NHS while the private sector drank tea in china cups and washed its hands of such indelicate, unprofitable situations



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