An idea that could smash the clinical silos

By placing junior doctors in the most innovating organisations we could create a more open-minded culture, writes Nishma Manek

“What might have struck a non-partisan onlooker was the extraordinary inability of health leaders to reflect critically on their own failings, preferring instead to blame others”.

Richard Horton’s recent comment in the Lancet is an uncomfortable read. He argues that doctors are too quick to blame politicians for the NHS crisis. Our own inertia to work differently, rethink pathways and make the issues we complain about our defining concern are apparently equally to blame.

“For 35 years I have watched doctors claim that the NHS is in crisis. It is not surprising that politicians have become deaf to our cries of imminent catastrophe”.

My response took me through the grief cycle. Firstly denial (‘it’s not our fault’), then anger (‘it’s unhelpful to shift the spotlight’), to bargaining (‘give us more money, and the rest will follow’), depression (‘could he be right?’) and finally, I ventured into acceptance (‘there might be something in this’).

Perhaps he, like Jessie J before him, raises a pertinent question – is it all about the money?

It’s tempting to lay the blame exclusively at the feet of the politicians, and slope off quietly to keep working in the same way. Of course, money is part of the problem. But given the rate at which health inflation and demand are increasing, I can’t imagine a time when we’ll say we have enough. Even if we can find more money, there’s now resounding agreement that it should go into social care.

Missed opportunity

Here’s a thought experiment. Would reaching the ‘acceptance’ stage help us to concentrate on getting the best return on investment for what we have, and systematically focus on improving quality and meeting need? Whilst there are exemplars dotted around, his point about our collective inertia to working differently hit a nerve.

Clinicians don’t easily cede to disease. We don’t waste much time lamenting its presence or its complexity. We invest in exploring all avenues, we treat what lies in our control, we innovate and push the limits of our toolboxes to do what we can for our patients.

But do we consistently apply the same thinking to how we work?

The phrase ‘new ways of working’ can feel vague. Ask most junior doctors what it means, and you’ll get a nonchalant shrug. But I think that’s a missed opportunity.

I’d have shrugged too, if it wasn’t for a fortunate twist of fate. Luckily, I spent time in paediatrics at St Mary’s Hospital in my GP training, and saw their ‘Connecting Care for Children’ model.

The paediatricians and GPs in the area felt that, with the right expertise, some of the hospital referrals could be avoided. Practices come together in hubs, and now GPs, paediatricians and other healthcare professionals discuss patients within a monthly clinical multidisciplinary team meeting. They can then refer patients to an ‘outreach clinic’ for those still needing to be seen, led jointly by a consultant and a hub GP practice every few weeks. The model is supported by a direct phone and email line between GPs and consultants.

The consultants are focused on doing the right thing for their patients. And that might mean keeping some from reaching them altogether. Even before the term vanguard entered our lexicon, they were reducing A&E and outpatient attendances. They achieved this by thinking differently, focusing on meeting need rather than perpetuating the same old inefficiencies, and investing in building relationships.

One particular observation from my time there stayed with me. There are two groups that seem to have the most empathy for colleagues on both side of the fence: patients, and junior clinicians. I suspect it’s simply because they usually spend time in primary and secondary care, and often in quick succession. They’re closer to the paths that weave between the two, and to the care that falls into the cracks.

But after this, most of the communication that happens between sectors is through paper – through the referrals, clinic letters, or (if you’re really lucky) the faxes that drift back and forth. The value that comes from actual face time in both camps is incomparable, in terms of the trust and relationships it can foster. Yet once you step out of training, it becomes less common. But does that make sense, when it’s later in our careers that those insights could matter most?

Models like ‘Connecting Care for Children’ are changing that. As a trainee, being in this environment subtly expanded my imagination of how we could be working. It was far more powerful than reading a case study in a glossy publication.

Is there something we can learn here?

Grief cycle

Medicine is a vocation, and a complex one. So trainees are inclined to take cues from our ‘masters’ – and if they appear relatively successful in their silos, why would we consider working differently?

Perhaps the real opportunity to seed that culture change has been overlooked. Instead, what if we ensured all junior clinicians trained in places that are actively trying to innovate?
Unlike Richard Horton, I haven’t spent 35 years watching doctors claim that the NHS is in crisis. So I don’t think I’m at the acceptance stage of the grief cycle just yet.

But the prospect of spending the next 35 years doing so isn’t too appealing either. Tackling the inertia to work differently feels like an attractive investment. But it will be predicated on forging relationships, building trust, and changing our culture – all of which take time.

So why not start that journey much earlier in our careers?

I’d put money on that giving us a much better return.

Dr Nishma Manek is a GP trainee and national medical director’s clinical fellow to Dr Arvind Madan.