These days, I rarely forage for myself in the evening, so frequently do I attend dinners of one sort or another. They attract an interesting cross section of people - managers and clinicians, as well as some who are both, policy wonks and observers, all discussing how the NHS is changing.

It struck me recently that the further away from the coalface people are, the more likely their observations are to have a ring of truth to them. Perhaps distance enhances focus.

One such observation was that the NHS was a collaborative system in which organisations work together to provide care. While one doctor present scoffed at the idea of the NHS as anything more than a collection of organisations, I was just relieved that nobody was pretending the system was a market.

But the suggestion left me wondering about the use of the term collaborative. I have not seen much evidence of collaboration in recent months. Something between thinly veiled obstruction and suppressed resentment would be more accurate.

Leaps and bounds

I recently had the privilege to take a tour of the Wellcome Collection. Henry Wellcome amassed some incredible curios, including a group of amputation saws dating from the 16th to the 19th century. The main design change evident over this period was that the handles became less ornate - a nod in the direction of infection control perhaps?

Considering the progress in surgery over the last two decades, I appreciated what an incredible era we live in. Increasing numbers of procedures are now feasible through a modified telescope, obviating the need for a large scar and enabling patients to go home on the same day or soon after. Less than 25 years ago, a two-week stay might have been required.

Progress in medicine has been phenomenal by any benchmark. Sadly, the same cannot be said of the way in which people access healthcare or of how the system is structured.

Choose and book

Why is it that 60 years after the NHS was founded, the vast majority of people are still expected to see their doctor and be referred to a specialist, and then work through a sequence of subsequent appointments, just as it has always been done? I had naively thought Choose and Book - which I used recently as a parent - might at least foster some healthy competition and help to improve the timeliness and flexibility of appointments.

When referred by my GP recently, I picked one of 15 hospitals for an appointment - on the basis of its short waiting times, geographical convenience and because it was a teaching hospital. Imagine my disappointment, on arriving at the clinic, to find they had no record of the booking and no referral letters or details.

Ninety minutes and two re-parkings of the car later, the letter - which I had watched being completed on the web - finally arrived by fax. The receptionist was charming and apologetic, apparently determined to speed things up as much as she could. However, from behind the reception desk came an ugly display of temper and invective - an internecine war was breaking out between colleagues who did not want to help out beyond their own territory. The staff seemed oblivious to the fact that patients were witnessing this unseemly spectacle. Certainly no spirit of collaboration here, and that was within one organisation.

Changing demands

We know that in some cultures attending the GP and seeking medical help in this way is not the norm. Some groups, often in more deprived areas, prefer to walk in to a service at any time and be seen with their acute problems. Under 40s also seem less fussed about seeing the same doctor at each visit. Perhaps this is because they have greater self-reliance in determining whether a service is safe or high quality, being able to research it themselves.

People from this age group are increasingly accessing services from work - either through a private GP or a walk-in service, which may be operated by a number of providers and may not have a GP on site. The same generation of service users are finding their next job and booking restaurants and holidays online. Increasingly, they will access healthcare in this way - Googling a service and turning up on the basis of performance indicators like waiting times, the ability to walk in and the range of services offered.

While this may not work for somebody with a long-term condition or multiple co-morbidities, by the time Generation Y reach that point, they will expect something more fleet of foot and fit for purpose than is currently available. And after my recent experience, all power to them.

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