BLEEP OFF!

Why calling another specialty can feel like stepping into enemy territory

At some point in our careers we’ve all been there. The ward round extends past its third hour, and just as your brain starts to give in, your consultant turns to you and says (with the confidence of someone who hasn’t made a bleep in ten years), “Can we get psych to see this patient? He’s been... a bit low since his amputation.”

You glance down at the notes tightly scribbled on your list: “Patient upset over past week – psych referral” sits just above another patient: “22-year-old female with pelvic pain – Gynae + GUM opinion?” You wonder whether it would be faster to refer her to every specialty alphabetically and let them fight it out amongst themselves.

Every day across the NHS, inter-specialty referrals are made in the thousands—often by resident doctors. A 2019 BMJ study estimated that between 10% and 20% of referrals made in secondary care settings are unnecessary or inappropriate, often due to lack of confidence, defensive medicine, or even, sheer habit. Defensive referrals are common, driven by the fear of missing something rather than clinical necessity.

Why So Hostile?

There is an unspoken hostility baked into referral culture. It's hard to name another profession where a standard method of inter-team communication involves a 20-minute phone call that may open with a sigh and end with a subtle (or event overt) questioning of your competence.

Every speciality operates with its own boundary. The acute abdomen, that belongs to the general surgeons. The PV bleed, that belongs to gynaecology. Doctors go through great effort to define, defend, and protect the borders of their role. Boundary defence is sometimes about workload protection. In a resource-starved system, every specialty becomes increasingly motivated to reduce ‘unnecessary’ work. So when resident docs refer “just in case,” they activate a defensive reflex in the receiving team: “This isn’t our job.”

The result is an ever growing feedback loop - unclear referrals lead to irritable responses; irritable responses lead to more hesitant, overcautious doctors; hesitant doctors make worse referrals—and around we go. One study from NHS Digital found that when structured referral templates (like SBAR) were implemented, referral clarity improved by over 30%, and rejection rates dropped significantly.

This makes resident doctors the perfect scapegoats for inter-specialty friction. The senior makes the call, the junior makes the bleep, the registrar unloads, and no consultant ever hears the feedback.

There’s something called rotational capital. As resident doctors are often transient, they don’t get to build the inter-specialty relationships that could humanise future referrals. We are more forgiving to those faces that we know, and conversely, when anonymous or relatively unknown, we can be quick to reveal the worst parts of our nature.

Will we see progress? Well, there are no national targets for respectful inter-specialty communication. No audit codes for emotional safety. These things are difficult to measure objectively. Yet every doctor could tell you which specialties are “good to refer to” and which ones make you want to hide in the mess.

The Doctor Pay ‘Rise’ Explained - Who’s Really Winning?

The government has finally confirmed this year’s pay award, accepting the DDRB’s recommendation of a 4% uplift—up from the previously planned 2.8%. Resident doctors will receive an additional flat payment of £750 (totalling up to 6% for the lowest paid doctors), while consultants will only receive the 4%.

However, flat pay increases raise some issues. A £750 uplift means 2% for an F1, but only 1.2% for an ST1—doing least for those at higher grades. Consultants don’t see the £750 at all. This is an issue as it bands all pay grades closer together - as doctors progress and take on more responsibility, the relative increase in pay shrinks right up to the top level.

Inflation this month stands at 3.5% (CPI) and 4.5% (RPI, which includes costs associated with home ownership). Unlike previous spikes, this rise isn’t driven by consumer overspending and your average folk having too much money to spend. Instead, the bulk of the 0.7% increase from last month is down to higher costs for electricity, gas, and water.

The treasury has told ministers it has only allocated pay rises of up to 2.8%. Could this mean Rachel Reeves is planning future departmental cuts or further tax hikes to fund these public sector pay rises?

Reports say that all uplifts will be backdated to April 1st and should appear in August pay packets. The headlines are already calling it “inflation-busting”, and pointing to the fact resident doctors have been given the highest pay award in the public sector. For many however, this marginal increase above inflation leaves resident doctors too far away from the full pay restoration that they want.

The Irony of the "Simple Case"

Why experienced judgment still trumps automated escalation — and what happens when it’s missing

There’s a quiet, persistent irony at the heart of NHS planning — One the On-Call team are calling: The Irony of the Simple Case.

It starts with a well-worn assumption: Doctors are expensive - They are expensive to train and will receive salaries that are relatively higher than the rest of the workforce (especially once progression is taken into account) and that only complex patients truly require doctors. Everyone else — the “straightforward” cases — can be triaged, signposted, delegated. The MAP (Medical Associate Professional) project is built on this premise. So is the reconfiguration of out-of-hours GP services, once dominated by experienced GPs and at times, triage nurses, now replaced by NHS 111 algorithms and non-medical call handlers.

The catch is that the idea of a case being "simple" is only ever obvious after the fact.

Medicine is not like engineering or accounting, where your fixed inputs lead to predictable outcomes. It is an interpretive science - a discipline that lives in uncertainty. The patient with chest pain waiting to be seen; Nine times out of ten, it's muscular or stress-related. But on the tenth, it's an evolving MI or aortic dissection. The backache? Usually mechanical. Occasionally, it indicates a serious abdominal pathology. The real irony is that it takes expertise to rule out the need for expertise.

The Tyranny of Caution

To avoid missing that 1-in-10, the system has evolved to become algorithmically risk-averse. NHS 111, in particular, is designed to err on the side of caution — and rightly so, given its remit. But the result is that thousands of patients are redirected to A&E or UTCs unnecessarily. These patients often could have been safely managed in the community — had a GP, or even a trained triage nurse, been the first point of contact.

On paper, someone has been paid handsomely to create a report that shows the 111 model looks cheaper than paying a GP. But who’s adding up the costs of all the escalations that follow? The duplicated tests? The bed days? The stress placed on already-stretched acute services?

This same paradox plays out wherever “simple” cases are diverted away from doctors — whether to MAPs, paramedics, or AI chatbots. Delegation makes sense in theory, but in practice, complexity hides in plain sight.

“When I was a trainee, the “wise man” of the department told me to choose my colleagues first when looking for a consultant post and only after that the location, sub-specialty, job plan, etc.”

“The Medical SHO is the NHS punching bag. Knowledge to know they should be treated better, powerless to do anything. The canary in the coal mine of every NHS hospital - For the Med SpR however, the biggest difference is that you have more autonomy and freedom to make decisions; you are more respected by your seniors for being proactive”

“Yes doctors do make mistakes. The best do. Even Messi misses the odd penalty but that didn’t mean that he was replaceable by Johnny who could barely kick a football 20 yards.”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

NHS admin challenges continue to persist. Check out this excellent breakdown by The Kings Fund on the ways to tackle administrative issues within the NHS.

Back in 2015, TES magazine made a prediction that in little more than a decade’s time, children of doctors and lawyers could soon be priced out of private education, as fees continued to rise faster than wages. Fast forward to this week: The Times reports a record drop of 13,000 pupils in private schools over the past year — the biggest fall since ISC records began in 2012 — largely blamed on the introduction of VAT on fees.

The NHS is establishing a network of specialized mental health accident and emergency (A&E) units to alleviate pressure on traditional emergency departments and provide targeted support for individuals in mental health crises. (The Guardian)

Weekly Poll

Last week’s poll:

Do you think the BMA has played its hand too early by opening the strike ballot at the end of this month?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

Rethinking Frugality: The Art of Intentional Spending

You've been told to be frugal. Sensible. Prepared for the future. Yet, like clockwork, your salary hits your account—only to vanish to your expenses.

But have you considered that frugality isn’t about hoarding pennies, it’s about priorities. Open your banking app and look closely—do your expenses fall into shelter, health, learning, or meaningful experiences? If so, you're not wasting money, you're investing in your future self. That being said if you are on first-name terms with the staff at the local Michelin-starred bistro… maybe dial it back a notch.

Use that skill of triage and apply it to your finances. Try to cut the unnecessary and keep the essentials. Frugal living isn't about saying "no" to spending—it's about knowing what deserves a "yes."