Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Climbing out of our silos

BMJ 2020; 371 doi: (Published 06 October 2020) Cite this as: BMJ 2020;371:m3875

Read our latest coverage of the coronavirus outbreak

  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

At the start of this pandemic, fear and uncertainty led to a “blitz spirit” of cooperation across the medical arena: we all needed to pull together or the good ship NHS would sink, taking us and our patients with it. Six months on, everyone is tired and fractious. Feeling overworked and underappreciated, many of us are looking over our shoulder for someone to blame.

Hospitals have huge backlogs of elective work, and primary care is struggling as some specialties have still not reopened to referrals. I tried to refer a patient recently but was told that the department “could not hold the clinical risk”—whereas my lack of expertise was presumably not a problem.

Many secondary care clinics are running with remote consultations, which can be effective, especially for follow-up. However, they generate work previously done at the outpatient clinic: I now regularly receive letters asking me to initiate new medication, organise blood tests, and titrate doses according to the results. Our phlebotomists are overbooked, and GPs are muttering about feeling like community juniors. Our local medical committee advises us to refuse these requests, but I worry about the patients stuck in an argument not of their making, which may delay their diagnosis or treatment.

Hospital doctors are similarly aggrieved. I’ve heard complaints about inadequately assessed patients sent to the emergency department who could have avoided hospital if they’d been seen face to face. The telephone is great for triage, and of course it’s sensible to send patients with new, clear cut symptoms of stroke or heart attack straight to hospital—but often the diagnosis is clear only when you’ve examined the patient. This would have happened pre-pandemic, and it should still happen now.

When I started as a GP, the pace of life was different. Back then we had a programme of weekly lunchtime lectures, where we met each other and our hospital colleagues. Now lunch breaks are an alien concept, and we have few occasions to build relationships across the divide. But those relationships are important. When I ring with an urgent referral and find myself talking to someone I know, the conversation is much easier. Talking to doctors from other specialties, taking time to understand their perspective and appreciate the obstacles they face, helps us to be kinder to (and about) our colleagues.

We’re all in this together. We’re all scared about what happens next, for ourselves, for our patients who may get covid-19, and for the rest who will have their treatment disrupted or delayed. We must remember that last winter, pre-covid, was far from a halcyon age of peace and plenty in the NHS: hospitals were overflowing, and emergency departments were backed up with patients on trolleys. Doctors need to stand together and direct our criticism where it’s deserved: at those responsible for the disastrous handling of this pandemic and for a decade of underinvestment in our health service.


This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.