Quick summary: Systemic pressures, organisational shifts, and rigid professional frameworks frequently clash with the lived realities of patients, leading to miscommunication that damages trust towards healthcare services. When clinicians operate strictly through administrative or diagnostic lenses without acknowledging patient perspectives, individuals are often left feeling dismissed, which directly undermines psychological safety and overall well-being. Improving transparency around decision making and adopting trauma-informed communication strategies are essential steps towards protecting mental health, strengthening the therapeutic relationship, and delivering meaningful care within overstretched healthcare systems.

Seeking help when we are physically or emotionally vulnerable is itself an act of hope. Whether we are looking for understanding, care, support, or a cure, we usually expect something helpful to come from the encounter. Yet feeling uncared for, dismissed, or treated insensitively in healthcare is something many of us can relate to, particularly amid resource scarcity, long waiting lists, fragmented care, and the wider social and political landscape affecting wellbeing.

The Office for National Statistics found that over 70% of people reported positive experiences of UK healthcare services, suggesting that many people’s hopes were met. However, tensions around accessibility, communication, and service delivery remained, particularly around the loss of human connection and continuity of care that can accompany increasing digitalisation.

Previous research into people’s experiences of primary care has found a striking sense of disconnection, with some patients describing their GP as a stranger. It has also highlighted experiences of fighting to gain access, feeling dismissed, depersonalised and devalued, becoming resourceful out of desperation, and knowing that something was wrong. This suggests that systemic barriers, alongside problems in the relationship and communication between clinicians and patients, can become a significant part of the experience of receiving care.

As an NHS relational therapist, I frequently encounter the impact of these experiences in therapy. Many clients bring fears of being let down or dismissed by healthcare services into treatment and, at times, into the therapeutic relationship itself. Trust can therefore take more time to establish. It can require particular care around the beginning and ending of therapy, as well as around the inevitable misunderstandings and ruptures that occur in any relationship.

A relatively minor mishap can feel very different to someone who has repeatedly experienced healthcare as dismissive or invalidating. It can feel like a repetition of something that has happened before. This is one reason why, as clinicians, we need to think carefully about how our own behaviour might inadvertently recreate distressing relational experiences. Trauma-informed principles, including creating emotional safety, are relevant here.

I have also experienced the frustration of working within, or alongside, services whose organisational dynamics can contribute to poor communication and iatrogenic harm for both staff and patients. Being a professional does not make me unfamiliar with being a patient. I can recall several interactions with clinicians that felt dismissive, insensitive, unclear, or poorly timed. I know what it feels like to have your hopes dashed, and how strange it can be to see an in-depth consultation reduced to a few rushed lines in a medical record.

Experiences like these leave us with a difficult choice. We can put our emotional response to one side and try to move on, or we can seek some form of reparation, knowing that this may mean embarking on a frustrating journey through complicated systems in search of validation and a sense of control. Neither option is particularly satisfying. Both can leave us feeling that what happened does not matter, or that we do not matter.

Sometimes, there really is only a limited amount we can control. In those situations, “picking your battles” may be the most sensible option, even if it does not feel fair. In other situations, speaking up and advocating for yourself can make a genuine difference to the outcome.

This article looks at some of the reasons these situations arise. I refer to them as healthcare miscommunication enactments. Drawing on cognitive analytic therapy’s “rule of three”, I want to look at what happens between the clinician, the patient and the organisation around them.

The organisation and wider context

The NHS is widely recognised as being under pressure. Some services are overstretched and under-resourced, while others are dealing with repeated reorganisations and changes in the way they are funded and delivered.

More recently, NHS England entered a process of being dissolved and merged into the Department of Health and Social Care, with implications across NHS services. Like most reorganisations, the intention is to improve outcomes. In practice, requirements for Integrated Care Boards to reduce running costs inevitably affect which services continue to be funded, which are remodelled, and which may no longer be available.

Changes on this scale do not happen without disruption. Time and resources can be diverted away from patient care. Reporting lines can become less clear. Responsibility for decisions about budgets, timelines and services can move from one place to another. To patients, very little may appear to have changed. Behind the scenes, however, staff may be dealing with considerable uncertainty, including changes to established structures, procedures and working relationships.

There can be an unspoken elephant in the consulting room as a result.

Clinicians may be trying to contain their own anxiety while also providing containment for patients. When the organisation around them is changing, communication about care pathways, treatment options and service processes can become vague, rushed or simply absent. A clinician may appear inconsistent or uninformed when, in reality, they are also trying to work out what has changed and what it means for their patients.

I have often heard clinicians describe working in these circumstances as being “like nailing jelly to a wall”. It is an expression that captures something about the experience. The task can feel unrealistic, messy, absurd and almost impossible.

This is not about asking patients to feel sorry for clinicians. It is about recognising that system pressures do not stay neatly outside the consulting room. They can find their way into conversations, relationships and decisions, and ultimately contribute to experiences of poor or dismissive care.

When professional frameworks eclipse patient reality

Poor communication in healthcare is not a new problem. For patients, however, it can feel intensely personal.

We do not arrive at a healthcare appointment as blank slates. We bring our histories with us, including previous experiences of illness, trauma, vulnerability, relationships and healthcare. What has happened to us before can influence what happens in the room now.

There is also a wider question about whose account is taken seriously. Previous research has shown that people who are ill can be particularly vulnerable to having their experiences and accounts discounted in healthcare. Other research has highlighted how inequalities in power and healthcare can affect people differently depending on the social circumstances and identities they bring with them.

Another aspect that can easily be overlooked is the complexity of multidisciplinary working. From a patient’s perspective, professional hierarchies, governing bodies, codes of practice and accountability structures can be largely invisible. Yet all of them can shape what happens during a consultation.

Different professional groups also work from different frameworks. They may have different priorities, terminology, responsibilities and ideas about what constitutes relevant information. Sometimes the communication problem has already happened between professionals before the patient becomes aware of it.

Professionals are trained to look at situations through particular lenses. These might include clinical guidelines, evidence, organisational policies, legal responsibilities and professional codes of practice. Those frameworks matter. They are there for good reasons.

Patients, however, are looking at the same situation from somewhere else.

We are thinking about our hopes and fears, our physical and emotional experiences, our values, our relationships, our circumstances and the practical consequences of whatever happens next. We are also living with the uncertainty of not knowing what the professional already knows.

Problems arise when one of these perspectives is treated as the only legitimate reality.

The clinician has professional knowledge and authority. The patient has knowledge of their own experience. Both can be true at the same time. Yet the balance of power in the consulting room means that the professional perspective can easily become dominant.

I see this particularly clearly when clients talk about receiving a mental health diagnosis. Some are surprised to discover that a diagnosis has been recorded without anyone explicitly discussing it with them. Others are puzzled that a relatively brief assessment has resulted in a label that feels significant and potentially life-changing.

Part of this can be explained by expectations not matching reality. But there is also a difference between the way a clinician and a patient may understand what has happened.

An NHS psychiatrist may be working from a professional frame of reference shaped by clinical experience, diagnostic criteria and professional judgement. The meaning that a diagnosis has for the patient may not always receive the same attention. The diagnosis is then entered into systems that may be focused on documentation, communication between professionals and organisational requirements rather than on how the patient experiences the information.

The result can be surprisingly confusing. Something that is intended to provide clarity, validation or access to treatment can instead feel invalidating.

And there are times when communication failures have much more serious consequences. The Francis Report highlighted how failures in communication, governance and organisational culture can contribute to poor care and serious harm.

I have experienced a smaller version of this dynamic myself. On one occasion, a GP told me that I must have misunderstood or misheard valid advice given to me by a clinician from another department because, from the GP’s perspective, only a GP should provide that information.

I decided not to challenge the interaction because I got the outcome I needed. Nevertheless, I left the consultation feeling patronised.

The point is not that the GP was necessarily wrong to follow their professional framework. The problem was what happened when that framework became the only version of reality that seemed to count.

Of course clinicians need to follow guidance. They need to work within their professional responsibilities and the limits of their knowledge. The question is how this is explained to the person sitting opposite them.

There is a significant difference between saying, “This is the only possible explanation”, and saying, “Based on what I know and the information available to me, this is what I think, but there are still some uncertainties”.

The second approach does not undermine professional authority. It gives the patient a clearer understanding of where that authority is coming from.

Without that distinction, patients can leave consultations feeling unheard, doubted or unable to reconcile their own experience with what they have just been told. This does not necessarily mean that the clinician was wrong. It may simply mean that the clinician’s perspective, reinforced by the power of the professional role, became the only perspective allowed in the room.

Add organisational pressure to this. Add overstretched clinicians, competing targets, limited appointment times and the emotional demands of the job. It becomes easier to see how communication can become dismissive even when nobody intended it to be.

There is another complication. When organisations are uncertain, professionals may understandably rely more heavily on rules, policies and established frameworks. These can provide some stability when everything else feels unstable. They can also serve a defensive function, particularly when staff are worried about complaints, blame or litigation.

The problem is that this can make it harder to see how the interaction feels from the patient’s side.

It is difficult to provide genuinely trauma-informed care when the organisation itself is creating experiences of uncertainty, disempowerment and invalidation for the people working within it.

Good-enough communication may lead to good-enough care

In my experience as both a patient and a clinician, care becomes easier to navigate when people are honest about where advice, decisions and information are coming from.

A disappointing outcome is often easier to accept when we understand why it has happened. A decision based on clinical judgement feels different when it is explained as clinical judgement. A restriction imposed by hospital policy feels different when someone tells us that a policy is responsible for it.

When that context is missing, something resembling medical gaslighting can occur. The patient is left trying to work out whether they misunderstood, whether they imagined what happened, or whether their own experience can be trusted.

For example, as a patient I was once told that a diagnosis appeared likely but could not yet be confirmed because further investigations were required under hospital policy. It was frustrating, but I could understand it.

In another situation, I was told that I could not possibly have a particular health condition, only for that diagnosis to be confirmed later.

The problem was not simply that the first assessment was wrong. The certainty with which it was communicated shaped what I expected to happen next. It briefly raised hope and then made the eventual experience of grief and disappointment more difficult.

What mattered was not only what I was told, but the frame from which it was being told.

If the uncertainty had been made explicit, or if the professional and organisational limitations behind the decision had been explained, I would have been better able to understand what was happening and adjust my expectations.

These are the kinds of situations I hear about from clients and encounter in my professional life.

Takeaway

If there are two things I hope we take from this article, they are that patients need acknowledgement as well as information, and that clinicians should be clearer about the frame from which they are speaking.

People want to know what is happening, but they also want to feel that their experience has been heard and taken seriously. Feeling understood and respected can matter almost as much as the eventual outcome.

Being explicit about whether we are speaking from a professional, personal, organisational or policy perspective can also make a considerable difference. It allows patients to understand why a decision has been made without being left with the impression that their own reality is somehow wrong.

Healthcare will never be perfect. Systems will remain complicated. Services will face pressures, clinicians will make mistakes, and sometimes there will simply be no good option available.

But even in those circumstances, there is usually a choice about how we communicate. In stretched, fragmented and imperfect healthcare systems, that may be where good-enough care begins.

Lorraine Welch is a cognitive analytic therapist in the NHS also trained in EMDR and MBT, with a core profession in mental health nursing.