Intended for healthcare professionals

Opinion Critical Thinking

Matt Morgan: Aggressive transparency is a tool for change

BMJ 2023; 380 doi: (Published 24 January 2023) Cite this as: BMJ 2023;380:p154
  1. Matt Morgan, consultant in intensive care medicine
  1. Western Australia
  1. mmorgan{at}
    Follow Matt on Twitter: @dr_mattmorgan

Health services around the world are sinking. They’re facing a storm—struggling to withstand the pressures of caring for an ageing population, of meeting higher patient expectations, and of trying to provide ever more brilliant, but expensive, new treatments amid the challenges of the post-pandemic world. The waves from these sinking ships bring workforce strikes and patient suffering. The NHS has recorded the highest number of excess deaths since 1951, and these pressures are felt further than the UK. International healthcare systems are also experiencing nursing strikes.

These strikes are not only about pay. Yes, governments should be ashamed when staff who cared for us in our time of greatest need are continuously in need themselves, visiting food banks and struggling to support their families. For some, however, concern runs deeper than the bottom line. It’s also about worth, fairness, a feeling of deceit, and moral injury.

When I treat a critically ill patient, what’s worse than having no treatments left to use is knowing that treatments are available but being unable to deliver them. For staff working in communities, emergency rooms, outpatient clinics, or ambulances, the inability to deliver care takes a moral toll. “We’re doing all we can” is vastly different from “We’re doing all you need.” As the American anthropologist and physician Paul Farmer said, “It is very expensive to give bad medical care to poor people in a rich country.”

These crises have solutions. I’ve previously written that struggling health services have three options: tax more, collaborate more, or ration more.1 But the people making hard decisions are drowned out by vacuous calls from government ministers for “public debate,” as though they’re planning a village hall meeting with dried out sandwiches and weak tea.

For real debate, and to support the people unable to deliver, what we need is what I call “aggressive transparency.” Instead of relying on journalists to expose what’s going on with endless freedom of information requests or leaks to the press, we need transparency from the government and those in charge of running our healthcare systems. In the pandemic, data dashboards came alive—with vaccination rates, death rates, and hospital admission rates. We need similar openness plastered on the entrances of hospitals and wards to inform the “debate,” now more than ever. Every ambulance could boldly display the numbers of hours it’s spent waiting outside the emergency department. Every GP clinic could pin up a poster showing its workforce shortages that week. Every ward could show the number of nurses it currently lacks. This could help beyond unloading moral guilt: it could nudge governments and decision makers into taking action.

By doing this, we lay the data bare for all to see. Not in a village hall or a newspaper but in the actual places where healthcare happens. We need to offload the moral guilt placed on healthcare workers—of conflating “We’re doing all we can” with “We’re doing all you need”—onto the decision makers who give bankers their bonuses, who give their friends PPE contracts, who give healthcare staff directions to the nearest food bank, and who give patients less than they need and less than they deserve.


Thanks to Dr Tim Bowles for helping to develop this idea.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Matt Morgan is an adjunct clinical professor at Curtin University, Australia, honorary senior research fellow at Cardiff University, UK, a consultant in intensive care medicine at the Royal Perth Hospital in Australia, and an editor of BMJ OnExamination.