Intended for healthcare professionals

Rapid response to:


Does improving quality of care save money?

BMJ 2009; 339 doi: (Published 11 September 2009) Cite this as: BMJ 2009;339:b3678

Rapid Response:

the blind leading the dis-empowered

In his editorial 'Does improving quality of care save money?'(BMJ
19th Sep p644), Appleby speaks of increasing rather than falling costs in
hospital care due to "error, adverse events & poor quality". He
mentions longer stays and an increase in pressure sore rates. At least he
cannot be 'shot' in his role as the mere messenger of a report by
Ovreveit, but together the authors display a frightening naievty as to the
real cause of the problems they describe, and therefore of the best
solutions. Perhaps it's pertinent to observe that Appleby is an economist,
and to ask when we might see a report on this theme from a coal-face full-
time senior clinician (and I dont include Darzi in this category!).

It's senior jobbing clinicians running their day-to-day services who
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, PCT demands,
short staffing, EWTD constraints and much more. The sanity-preserving
response has become to keep their heads down and get on under fire as best
possible rather than to apply the intellect which got them to consultancy.
Moreover, to get 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

Appleby wonders about addressing the problem by "providers bearing
the costs". We've all shrugged our shoulders at the daily-repeated and
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
that "saving money is not a prime motivating factor for clinicians".
Strange that, because it IS in the private sector where we are conscious
every day of the uninsured status of increasing numbers of our patients.

Its only really when Appleby and his ilk become aware that their
philosophising is the problem and not the cure that we'll get back to
productive and efficient secondary medical care. Just give us a proper
voice for once, just once, instead of the lip-service repeatedly paid
towards involving clinicians in policy.

Competing interests:
bread & butter working consultant

Competing interests: No competing interests

20 September 2009
Peter J Mahaffey
consultant surgeon
bedford hospital MK42 9DJ