Caught in the ‘no man’s land’ of care

Clear communication is vital between primary and secondary care, writes Ms Julie Price, Consultant Clinical Risk Advisor to Medisec

Effective timely communication among healthcare providers is central to safe care and is particularly important between primary and secondary care. It ensures delivery of high-quality care for patients in a collaborative and efficient way, whilst making the best use of clinical time and resources. It also facilitates continuity of patient care.

However, when this communication is sub-optimal, patients may find themselves caught in a “no man’s land” in their journey of care. Consequently, the patient may not fully understand the next steps of their treatment or who to contact for advice. This, in turn, may lead to frustration, delays in care, potential medication errors and patient harm. The focus of any transfer of care between primary and secondary care systems must be patient-centred.

Medisec recognises that clinicians are under extreme workload pressure, particularly in these unprecedented times, with increased waiting lists and delays in care. Therefore, it is now more important than ever that clinicians, from both primary and secondary care, ensure good communication between the sectors. In Medisec’s experience, claims and/or complaints often arise as a result of miscommunication or delayed communication between primary and secondary care.

The Medical Council’s ethical guide specifically references the importance of communication when handing over care to another clinician. It states in para 23.2:

“When you hand over care for a patient to another healthcare professional, team, and/or institution, you should check that they understand and accept responsibility for the patient’s care. You should pass on all relevant information about the patient and the patient’s care. When discharging patients back to primary care, you should give all relevant information promptly.”

Scale of the problem

A study by Dinsdale E, Hannigan A et al, published in 2020, highlighted deficits in communication between primary and secondary care. Data examining 3,293 referral letters and 2,468 discharge letters across 68 GP practices and 17 hospitals, across Ireland, was compared with international guidelines. Findings concluded:

Referral letters

• 82 per cent included current medications.
• 65 per cent did not include information relating to patient management up to the point of referral.
• 57 per cent did not detail medication allergies.

Discharge letters

• 30 per cent omitted medication changes.
• 33 per cent omitted medication lists.
• 13 per cent omitted secondary diagnosis.

The study also found that the median timeframe from referral to a response letter being received in general practice was four weeks. The shortest response time was one week from the emergency department and the longest was up to seven weeks from orthopaedics. A study published by Medisec (2016), in collaboration with University Hospital Limerick and a number of primary care sites (GP practices and pharmacies) based in the Mid-West, found that:

• Discrepancies in medication lists pre- and post-discharge was a common problem.
• GPs referred to the “lack of clarity” on discharge letters with regard to medication changes, clinical information, tests performed in the hospital, test results, etc.
• Some 46 per cent of participants described the relationship between primary and secondary care as being negative, a “disconnect” between the two sectors. Contributory factors to the negative relationship between the sectors included:
• Inadequate transfer of information, eg, no discharge summaries.
• Poor communication links, particularly between GPs and larger hospitals, where difficulties were experienced when trying to contact hospital doctors. Roy CL et al, (2005) reported that 41 per cent of patients were discharged from hospital with test results still pending. Both the requesting clinician and GP were often unaware of these outstanding test results, a proportion of which required further action.

Key risk areas at the primary/secondary care interface

The main areas of risk relating to sub-optimal communication between primary and secondary care are as follows:

• Admission to hospital

Good communication is paramount when a GP refers a patient to secondary care, whether as an emergency or routine referral. The optimal management of the patient may depend on the accurate and useful information provided by the GP. This information should include the patient’s past medical history, current medications, medication allergies, presenting complaint, and treatment provided to date, including test results carried out, reason or indication for the referral, and any relevant family history. Providing this level of information in referral letters ensures secondary care providers are fully informed and reduces the risk of inappropriate treatment/misdiagnosis.

• Medications

When patients are admitted to hospital, their medications may be altered. It is important that the changes are communicated to the patient and the primary care provider promptly on discharge to avoid confusion. Otherwise, errors can occur due to duplication, omission, or incorrect dosage, resulting in the patient experiencing an adverse event or suboptimal clinical management.

It is imperative that arrangements are clear with regard to who is responsible for follow-up and ongoing care. Challenges may arise if the GP is not familiar with the drug they are requested to prescribe and hence not conversant with dosages, monitoring side-effects and appropriate patient counselling. As a reminder, the clinician who signs the prescription has clinical and legal responsibility for that prescription.

Care should be taken when prescribing on the advice of other clinicians, eg, transferring a hospital prescription onto a GMS prescription. The GP should ensure that the patient has been counselled regarding the medication and possible side-effects. Where necessary, the GP should ensure appropriate monitoring and check that results are satisfactory prior to issuing the prescription. Remember, the clinician who signs the prescription has responsibility to ensure it is appropriate.

A hospital discharge prescription, presented to the GP by the patient, in the absence of a discharge letter, can often cause confusion. It is important that all alterations, increases, and decreases in therapy, including cessation and any initiation of new medication, are clearly communicated by the hospital clinician to the patient’s own GP.

• Discharge from hospital

Communication is a key facet of effective discharge planning. Before discharge, the hospital clinician should have a meaningful conversation with the patient to discuss their illness, future treatment plan, medications including any necessary monitoring arrangements, and any subsequent follow-up appointments. This information should be clearly included on the discharge summary to the GP, a copy of which should be stored in the patient’s medical records and ideally a copy provided to the patient.

When the patient is discharged from hospital, it is essential that all relevant information regarding the patient’s hospitalisation is promptly sent to the GP to enable a seamless transition of care to the GP following discharge.
HIQA has published standards regarding patient discharge information.

• Clinical governance of test results

The responsibility to review any test results and take appropriate action lies with the requesting doctor or clinical team.
When the patient is discharged from secondary care and there are still test results pending there is a danger that they will “fall between two stools”, ie, between two sectors of care, each sector assuming that the other has responsibility, with the potential for the patient to suffer harm.
Risk management tips

1. Standardise the communication between primary and secondary care at both referral and discharge. Include the following as a minimum:
   a. At referral

• Indication for referral.
• Past medical history.
• Current clinical status.
• Current medications and allergies.
• Results of any relevant investigations.
• Family history if relevant.
• b. At discharge
• Diagnosis and treatment.
• Known and pending tests results.
• Discharge medications, especially if changes have been made to a prior medication regime or if medication monitoring is required.
• Recommended follow-up and required monitoring.
• Engagement of other services, eg, public health nurse, physiotherapist etc.
• Ensure that the discharge summary is promptly sent to the GP. Consider providing a copy of the discharge letter to the patient. Ideally, the transmission of all patient identifiable information should be sent via “healthlink” or “healthmail” to ensure the information is transferred securely and in a timely manner.

2. At both referral and discharge engage with the patient and hold a meaningful discussion using plain English about the nature of their illness, medication prescribed including any monitoring required, and follow-up including subsequent appointments. It is important to make a note of these discussions in the patient’s medical records.

3. Both primary and secondary care providers should undertake a medication review for high-risk patients, eg, polypharmacy, at or following discharge to avoid medication errors such as omissions, duplication, dosing errors, or drug interactions.

4. Ensure all tests requested are followed up appropriately and results communicated to the patient. Unless agreed otherwise, this should be the clinician who ordered the tests.

In summary
Evidence suggests that significant communication gaps exist between primary and secondary care. There is potential to improve the patient’s journey between the sectors, and reduce the risks of patient harm, claims or complaints. Good timely communication is an essential component of transition from secondary care to primary care and key to reducing confusion and minimising patient harm. Involving the patient in their care at both referral and discharge is of paramount importance to providing seamless care.

References available on request