Something I have noticed over the years is how increasingly restricted we have become in our clinical practice. Once upon a time our employers allowed us, as Consultants, total clinical autonomy. Indeed this was one of the conditions demanded by the BMA before they would agree to co-operate with the formation of the NHS. Increasingly this clinical autonomy is being lost, as managers control clinical practice by over rigid enforcement of protocols and guidelines many of which have little evidential base. Another example is referral management as described here. The concept of clinician discretion is gradually being lost. This culture of resigned obedience culminates in the sort of bunker mentality which afflicted the staff at Stafford hospital, too intimidated to speak out. The BMA of 1948 considered clinical autonomy one of its highest priorities. The BMA of 2010 is not the same.