Intended for healthcare professionals

Opinion Talking Point

John Launer: Preventing a mismatch of agendas

BMJ 2024; 384 doi: (Published 28 February 2024) Cite this as: BMJ 2024;384:q353
  1. John Launer, GP educator and writer
  1. London
  1. johnlauner{at}
    Follow John on Twitter: @johnlauner

Some time ago I received a hospital appointment that I wasn’t expecting. I’d seen the consultant only a few weeks previously, so I phoned to inquire why I was being invited back. I discovered that it was for a review clinic, run by a specialist nurse. I was rather pleased and delayed a planned break to attend.

In my experience both as a health professional and as a patient, clinics run by nurses are good news. Nurses tend to be more systematic in their clinical reviews, often seem more attentive than doctors, and are more inclined to learn from patients and offer guidance about self-management. I hoped that the nurse might also provide some continuity of care and access by phone or email when I had a query about my condition—as well as being a conduit for contacting the consultant if necessary. These things matter to patients more than we sometimes think.

The nurse was kind, even though the consultation was mainly based on her filling in a questionnaire about my symptoms and medication. It was also clear that my records included inaccuracies and omissions—not her fault, of course—so we spent some time setting these right. This rather felt as though I was looking after the system instead of vice versa.

Only at the end of our conversation did she mention that the clinic was designed just to find out if there was any need to adjust my treatment. Since my symptoms were stable and my medication had remained the same for several years, she was discharging me back to regular consultant care. This would be my first and last appointment with her. My hope for some kind of continuity of nursing was clearly misplaced.

On the scale of human disappointments, this experience ranks pretty low. It was a mild annoyance, not a disaster. At the same time, it encapsulates so much that goes wrong in the health service in terms of poor communication, a lack of reflection, and not involving patients. It would have been easy for them to send me an explanatory letter with my appointment, giving me the choice of whether to attend. It wouldn’t have been much harder to make a phone call to find out if I wanted the appointment or to ask if there was anything else I needed.

At an organisational level, whoever set up the service could have thought it through beforehand with a planning group of other professionals and patients, including how to make it most effective. They could have introduced a system for eliciting feedback from patients and adjusting the service to prevent a mismatch of agendas. You don’t need a masters in complexity science to know that the best intentions can sometimes lead to unintended consequences.

We so often run services in the NHS as though the only important thing is the content they provide. In reality, clarity and transparency about contexts and expectations matter to patients just as much, if not more.


  • Competing interests: None declared.

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