Intended for healthcare professionals

Views And Reviews No Holds Barred

Margaret McCartney: Let’s start talking to colleagues

BMJ 2018; 361 doi: (Published 16 April 2018) Cite this as: BMJ 2018;361:k1602
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}
    Follow Margaret on Twitter at @mgtmccartney

It’s hard to escape the feeling that the NHS is in terminal decline. Underfunding: check. Spending on non-evidence based systems, interventions, and re-disorganisations: check. Low morale: check. And junior doctors, the canaries in the hospital mine, putting their training programmes on ice: check.

I understand why juniors might want to do this, but I’m dismayed that the NHS is not a good enough offer. The 70th birthday of the NHS should be a cause for celebration. The nation is proud of the NHS, its collective nature and the contribution to it, and the societal leveller it creates.

David Tang, a prominent businessman who died last year, was more familiar with the private sector and wrote of his first experience of the NHS in a Nightingale ward. “It had never occurred to me that sharing with other patients and seeing the dependable shadows of the moving and half-whispering nurses could engender such a soothing and warming feeling,” he said. “I also felt a bond with my fellow patients.”1

We can talk about funding arrangements, quality adjusted life years, randomised controlled trials, and cost effectiveness calculations, but the NHS is also something that’s valued emotionally. Working for it, or using it, is not just a monetary calculation. When the NHS fails it also fails us in our hearts.

I still come across old, thinned notes, where the GP has referred a patient to a consultant he or she clearly knows, and a letter back briefly saying, “I don’t think there is anything sinister going on here, but please refer back if concerned” or, “I have reassured this child and his parents” or, “I have arranged for her to come in for further tests.” There’s a feeling of mutuality and trust, a tight circle of people with detailed knowledge doing their best for the person at the centre.

I compare that with the situation today, where it can take 40 minutes on the phone to negotiate between the people in charge of medical, surgical, and geriatric admissions—where, unless the “right” form is filled in, a specialist psychiatric service will decline a detailed referral, and where we use a call centre to communicate with our vitally important district nurses.

It can take 40 minutes on the phone to negotiate between medical, surgical, and geriatric admissions

Referring a patient can seem like a lottery, and the rapid turnover of patients exiting the hospital often means more investigations to be chased up and considered after discharge. This isn’t the fault of individuals: it’s a whole system problem.

Every bit of the system is trying to avoid doing more work because it is overstretched. The system feels fragmented, it feels unsafe, and it feels as though we no longer know each other. Colleagues who should be on the same side must instead press their claim for their patient, in a competition for resources. It’s miserable.

The best celebration for the NHS would surely be for us to start talking. Grand rounds or collegiate meetings could begin again, for all players in the multidisciplinary team to attend: from GPs to porters, to consultants, dietitians, physiotherapists, and hospital managers. People make the NHS; and people, in the end, are the only way to make it work. It’s not just patients who benefit from collegiality.