health

Shouting or talking? How to fix the Primary Secondary Care Interface.

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I recently wrote about the Primary Secondary Care Interface and how we came to write our Consensus on this. There have been many attempts over the years to improve the situation. Frequently this has involved GPs looking to push back to hospital colleagues when they are asked to undertake work they feel should have been managed within the secondary care setting.

Local Medical Committees can be very active in this, encouraging GPs to ‘just say no’ to work being passed to them, and the BMA has previously provided template letters to facilitate this push back.

The kinds of things we are talking about here are:

  • A consultant seeing a patient in clinic, deciding a new medication is indicated and then asking the GP to initiate this, without any indication as to whether appropriate counselling has taken place with the patient. This results in the GP having to pick up a conversation with the patient (an additional unnecessary appointment).
  • Hospital colleagues not providing sicknotes to patients on discharge and telling them to go to the GP for this, or only providing a note for 2 weeks when the patient requires much longer (and telling them to go to the GP for an extension)
  • Consultant colleagues deciding an onward referral to another speciality is required but asking the GP to undertake this referral rather than arranging it themselves.
  • Hospital colleagues discharging a patient after arranging investigations and asking the GP to ‘chase up the results’ and deal with them (often with little understanding of the thinking behind the investigations being arranged).

For balance, there are examples from consultant colleagues where they feel frustrated by Interface issues:

  • GP referring for a condition that could easily be managed in General Practice but the GP has not followed appropriate national or local guidelines that would have prevented a referral.
  • GPs referring for potential operative procedures without checking if any other chronic disease is under control (patients with high blood pressure without recent BP readings or diabetes without a recent Hba1C)
  • GPs referring for clinic appointments when utilisation of the Consultant Advice and Guidance system would have been more appropriate (and quicker for the patient).

All of the above are frustrating for clinicians, and more importantly unhelpful for the patient leading to delays in consultation, investigation and treatment. In some cases there are clinical safety issues – if a GP simply prescribes on the basis of a letter without speaking to the patient and assumes pre-treatment counselling has occurred (and in fact it has not), patients may not be aware of important and serious side effects to be alert to (prescribing of dapagliflozin is a live example of this).

How to we fix this problem? As a GP it is really tempting to fire off a snotty, shouty letter to the hospital each time I receive a request that I feel should have been dealt with by them. I admit to doing this on occasion (although I try not to be too snotty, and provide good clinical reasons as to why I am asking them to do the work). My problem with this approach though, is that I’m not sure it’s really helping to bring about long term solutions.

We undertook a survey of GPs and consultants across Cheshire and Merseyside last year. This was to explore understanding of the interface issues being faced. As part of this we asked people to rank their priorities from a list we provided. One of the really powerful results from the survey was that the subsequent ranked order of priorities was exactly the same from both GPs and hospital consultants. We all wanted the same things. Even more striking was that the top priority, from both GPs and Hospital Consultants was felt to be the need for improved relationships between Primary and Secondary Care.

Relationships are key. I don’t believe we can solve the Primary Secondary Care Interface issues if we don’t seek to improve relationships between clinicians. Putting that as a more positive statement, in order to improve the primary secondary care interface, we must improve relationships between clinicians.

To do this, we need to do more talking, and less shouting.

Depending upon how old you are as a GP, you may not have worked in a hospital setting for many years. For consultants, you may never have worked in a GP setting. We simply don’t understand each other well enough. I don’t understand the constraints of the hospital system or your ways of working, and consultant colleagues don’t understand my challenges. We need to fix this.

There are a variety of ways we could consider doing this:

  • Joint GP-Consultant Educational meetings
    • This used to happen, much more than it does now. Regular lunchtime meetings held in the postgraduate medical centre. We would learn together and get to know each other.
    • Increasing demands at work have led to most clinicians feeling that they do not have time to nip out at lunchtime for education. We have lost something here.
    • Evening meetings are probably the way to go and there are examples of this being a success – systems need to do what they can to re-kindle joint learning opportunities.
  • Job shadowing
    • A GP using a day of their study leave and spending it shadowing a consultant colleague in the hospital, the consultant then spending a day in General Practice.
    • There is nothing stopping individuals organising this for themselves.
    • I would recommend this to any clinician.
  • GPs contributing to the junior doctor education programme.
    • I have taken the opportunity to provide education about discharge summaries to Foundation Year doctors at our local hospital. I found this as valuable as I hope they did. Not only was I able to articulate the importance of a good discharge summary, I learned a lot from them about how they work, and how being a junior doctor feels for them (it is certainly different to when I was a junior doctor in the 1990s!).
  • Social events
    • Socialising with colleagues is of great value. Getting to know them, talking about work (inevitable) and play (much more enjoyable!).
    • You can arrange big, formal things like a local NHS Ball, add on a meal to the education sessions (see above) or something more low key.
    • My personal favourite is to find out who lives local to you and arrange to meet up in a pub or café. Anyone can organise this by sending out the call “I’ll be at the Rose and Crown at 8pm on Thursday night, please join me”. The worst you risk is sitting in the pub drinking a pint on your own – but I bet someone will join you…

Improving the Primary Secondary Care Interface needs work by people on both sides of the interface. That work is so much easier if you have improved the relationships between the people involved.

How you do that is up to you. The thoughts above are purely suggestions. I would love to hear of your ideas though – what would work in your area? If you’re on Twitter drop me a line @DrJonGriffiths.

It’s time for less shouting at each other, and more talking.

Dr Jonathan is a GP and Associate Medical Director, Primary Care, for NHS Cheshire and Merseyside

@DrJonGriffiths