Intended for healthcare professionals

Opinion The Bottom Line

Partha Kar: If you won’t speak up, how will the world know you exist?

BMJ 2023; 382 doi: (Published 12 September 2023) Cite this as: BMJ 2023;382:p2051
  1. Partha Kar, consultant in diabetes and endocrinology
  1. Portsmouth Hospitals NHS Trust
  1. drparthakar{at}
    Follow Partha on X (formerly Twitter): @parthaskar

The leadership journey for me started pretty early in my career—as a trainee, in fact—before I moved on to a clinical director role within a year of my appointment. When I worked in local leadership roles, I sometimes wondered why national leaders rarely spoke out on things that clearly weren’t helping patient care. In this regard, my time in a national role over the past seven and a half years has been fascinating. I’ve been able to observe first hand why people in positions of power in the NHS so often choose not to speak up. In my experience there are about five main reasons.

Keeping the job

Many people think that raising their head above the parapet could compromise their position and their career, and they’ll lose their power to influence change. From personal experience, that’s mostly nonsense. I’ve found that a clear, loud voice centred on consistent values brings you more allies in the system, not fewer. The root of the concern here is, essentially, “What would I do if I lost my job?”—in terms of paying bills and a mortgage, as well as losing the sense of power a title can bring.


Mixed in with the above is the genuine fear of feeling threatened. The threat of being pursued by HR, the threat of being walked out of your job, the associated loss of finances. The recent Letby case has raised queries around “Why didn’t doctors do more?” Threats have their way of silencing: look at the way regulatory bodies such as the GMC are used by some individuals to harm careers, or how the GMC acts in those situations.1

The bigger picture

Everyone talks about the “bigger picture,” yet no one knows what it is. The idea that you should keep the bigger picture in mind, rather than speaking up, is rampant. However, if you look at the progress of the NHS in recent years nothing suggests that things have improved by compromising on some “smaller pictures,” whatever that might mean. In private, many leaders will vouch for their commitment to a particular issue, such as primary care or tackling discrimination. But when it comes to it, few of them say much about it in meetings. The belief is that “if I stay in the tent, it will be better”—even though it rarely is.

“I’ll be rewarded”

I’m intrigued by the idea that “if I don’t speak up, I shall be bestowed with finances, positions, or something else to help the greater good.” Maybe that does help at a personal level. At a system level, not so much. There’s a belief that being corporate means collaborating. The problem is that we confuse collaboration with collusion. The net result is that there’s not much benefit for patients. A gong may look lush on the mantelpiece but, beyond your personal glory, it hasn’t really helped anyone.

“I believe this because it’s true”

Finally, some people genuinely believe that their silence is warranted because the statement under discussion is simply true. This could apply to a whole range of issues: better pay for doctors (“They get paid enough”), more support for primary care (“They don’t work efficiently enough”), more specialist posts (“We’ll train others to do their job—doctors’ training is long and expensive”), or tackling racism (“It’s politically correct nonsense”). If any of those reasons translates into poor care for patients or staff, you don’t need to go looking for the reasons behind it—you’re one of the reasons. As the saying goes, “If you’re not going to speak up, how is the world supposed to know you exist?”

Personally, I believe that everybody should speak up, or at the very least the NHS must find ways to let people do so. At the moment it doesn’t, no matter how many “freedom to speak up” people are appointed. Has my style hampered me personally, in delivering outcomes or getting funds? Not at all. Continuing my full time job as a clinician in the NHS stops anyone from threatening me within national roles: it takes away the financial insecurity that might come as leverage for those who want to threaten, and it also gives far more credence to a national role when you work “in the trenches.” Having data, science, allies, and an active patient community behind me strengthens my resolve to ignore the politics and narrowmindedness and achieve what’s needed.

A common refrain I hear privately is how much I’m “admired” for my “bravery” or “uniqueness.” But this uniqueness arises from others shying away from doing the very thing they profess to admire. If people did it, it would be the norm, and healthcare would be in a much better place.

I’m aware that my ability to speak up is linked with my privileges, yet so many others have the same advantages and don’t use them as they could. I’d encourage future leaders to incorporate data, science, allies, and patients into your thinking, and I promise that you’ll deliver. Most importantly, you can do so without selling your soul or compromising your values—as long as you have them in the first place.


  • Competing interests: See Partha Kar is national specialty adviser, diabetes with NHS England and is author of the MWRES Action Plan to tackle racism in the medical workforce.

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