It was all a bit confusing. Lisa had apparently missed her hospital follow-up clinic the previous week, although she was not aware of this appointment; a letter from her consultant indicated that this had, in any case, been booked in error as her ‘surgical episode’ was completed during her hospital stay. If she had any ongoing symptoms she needed to make an appointment with her GP – so here she was. The discharge summary had been uploaded onto the GP’s computer, but seemed to bear little resemblance to Lisa’s description of events during her hospital stay. Things did not quite add up. The explanation for her ongoing symptoms might have been straightforward, but her GP was ‘flying blind’. What’s more he had only 8 minutes to solve this: barely enough time to get past the hospital switchboard. The clinic was already running late – he would have to make some calls at lunchtime and get back to her later….
I had intended to do this every year, although it never quite worked out as planned: the last time I spent a day in general practice was in 2009. Back then it had been an eye-opener for me – a realisation that the majority of primary care work was very different to the tiny portion that involved an interaction with a hospital team. Much has happened in healthcare over the past 5 years – a change of Government, a new Health and Social Care Act, a transition from PCTs to CCGs and a seemingly inexorable rise in workload. I was under no illusions that a Tuesday with the duty GP at a local surgery would be any less demanding than my usual ‘day job’ on the Acute Medical Unit.
And so it transpired: GPs are clearly busy. I lost count of the number of patients who came and went during the course of the day; some were straightforward, some more complex. The variety of decisions ranged from rheumatology to dermatology, gynaecology and psychiatry; the skills of the ‘expert generalist’ were on show from start to finish. Problems were solved; solutions were provided. The system worked smoothly……until Lisa arrived, to illustrate the frustrations which occur when patients make the transition to and from secondary care.
There was a time when almost every patient would have had a ‘routine’ hospital follow-up clinic appointment a few weeks after discharge. It was an opportunity to tie up loose ends; to ensure that blood tests, histology results and scan reports had been reviewed; a chance to answer any questions that the patient may have had about their hospital stay and subsequent symptoms. A dictated letter to the GP would follow, supplementing the information provided at the time of hospital discharge. Of course, in many cases this was all superfluous – the patient took a day off work, paid for parking and waited several hours to tell a very junior doctor that all was well; meanwhile Primary Care picked up the bill. It is not hard to understand why shifting ‘follow-up’ back to the GP seemed a logical solution.
We have shifted the work, but not the information. Old-style dictated discharge summaries were informative, but rarely reached the GP in time to be of any real use. The electronic discharge summary now arrives more quickly, but the quality is highly variable. Furthermore, shorter hospital stays often mean that test results are not available at the time the patient goes home. Finding the right balance between speed and quality of information when a patient leaves hospital often feels like a search for the Holy Grail. If we are going to expect GPs to provide early follow-up for patients discharged from hospital we need to find a better way to ensure accurate and timely information is available for this first visit.
Telephone communication used to be much easier – ten years ago if I phoned a surgery and asked to speak to a GP I would be immediately connected; receptionists now are more reluctant to interrupt GPs during a consultation and usually offer a ‘call back’ time. I can understand why this change has happened – workload, confidentiality and risk of ‘cognitive overload’- but it has added another nail to the communication coffin.
The solution may lie in information technology. Primary care IT clearly works well for the patient in primary care; hospital IT works – albeit slightly less well – for the patient in hospital. Locally, our hospital systems have certainly moved forward since 2009: we now have electronic prescribing, an easily searchable electronic document system and a user-friendly interface which allows results, patient records and letters to be accessed via a single log-in. The system on the GP’s desk was still slicker – a few clicks and the printer had churned out a prescription, blood forms, patient information sheet and a sick note; a similar process in hospital would probably have involved a search for a spare terminal, a temperamental printer and at least one re-boot – but we are moving in the right direction.
The current lack of an electronic interface between hospital and community is as frustrating as the difficulty in getting past the hospital switchboard or GP receptionist when we try talking to each other. In Lisa’s case, access to the hospital computer system would have been revealing – scan results, histology, blood tests and an operation note could have been reviewed with a few clicks of a mouse. At my hospital desk I could have achieved this; sitting quietly in the corner of the GP’s consultation room, I could only offer sympathy. The information is readily available; we need to find a way to make this information more accessible.
They say that you should not judge a man until you’ve walked a mile in his shoes; a single day in primary care may not have been the full mile, but provided me with a snapshot of the pressures which are faced by those clinicians working outside the hospital walls. Breaking down the communication barriers is crucial – we should definitely do this more often.
This makes me appreciate more than ever the shared ‘clinical work station’ portal system which we have in Aneurin Bevan Health Board. When I log. In in the morning I can see at a glance which of our patients are in hospitals in the health board, and who has been discharged or died. I can also track what has happened to referrals and appointments. I have pretty much the sane access to information as hospital doctors except I can’t see xrays- just reports. In fact when I visited MAU myself a few months back I was able to use my own login in the hospital to access records of patients.
Accessing this system during consultations means that I can check on the info you describe above. Yes it takes time but it us efficient. Sometimes things are still unclear and this is where I find email useful. Its not often that I need to find out something immediately when of course a telephone call might work best.
I hear that our system will soon be rolled out across Wales which will be very welcome!
Many thanks again!
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Thanks Anne Marie – this sounds like a very useful system.
Heather Wetherell said:
An excellent reflective piece Chris, thank you. It very fairly highlights the problems we all share on a daily basis as we try to ‘complete the jigsaw’ of a patient’s journey, using only the the snippets of information we have at our disposal. Improved communications between Primary and Secondary care has to be the next major Priority in Healthcare.
Very interesting blog. It is vital all doctors across all specialities work together to improve patient care despite the very trying times we now work in. Silo working will do none of us any good especially our patients and breaking down barriers between primary and secondary care must be a priority for us all
Reblogged this on karenpriceblog and commented:
UK context but a thoughtful reflection on the interfaces between Primary and Secondary care. Communication and information transfer. With all the technology available we are still not handing over the baton.
Simon F said:
Really interesting piece Chris, thank you. Well done for breaking out of the hospital to spend a day in primary care! I am sure return visits would also be invaluable. Totally agree with your comments. We need to build and strengthen systems such as the portal mentioned above to make this work better. Locally the Hampshire Health Record is a great resource with a lot of potential for transfer of clinical information in near-real time. Used it a lot as a GP. Also rich resource in anonymised form for research aiming to improve care quality such as here: http://www.clahrc-wessex.nihr.ac.uk/public-health-and-primary-care