The gap between primary and secondary care has sometimes been compared to ‘no man’s land’ – that area not quite owned or controlled by either party. But it is a potential source of risk to patients, particularly during the COVID-19 pandemic. Dr Rachel Birch, Medicolegal Consultant at Medical Protection, provides tips on bridging the gap.
(1) Prevention is better than cure. Be proactive and take time to consider what could go wrong before it happens. The COVID-19 pandemic is an unprecedented time in healthcare history. As well as the ongoing pitfalls of communication to and from secondary care, are there any particular and new problems that you have identified in your practice? What can you do to minimise any patients getting ‘lost in the system’? Are there any barriers to care that have not been recognised? Undertake this exercise regularly as new risks may emerge as others become less prevalent.
(2) Patients may have behaved differently since March 2020 and this may be continuing even now, months after the start of the pandemic. They may be frightened or may be trying to protect family members from risk of COVID infection. They may have financial or work pressures. Their mental health may well have been affected by the particular stresses and challenges they have faced these past few months. This might mean that they behave differently – for example, they may be trying to avoid attending the hospital or perhaps even the practice. Take this into account when considering referring patients to hospital and encourage patients to share any concerns.
(3) Routine hospital care ceased almost overnight back in March and the HSE took over facilities in many private hospitals in order to provide safe patient care. As we progress through the next few months, particular hospital services may well come and go slightly, depending on pressures caused by COVID as well as any potential future lockdown situations. It is important to keep up to date and be aware of which services are open and where they are being delivered, bearing in mind that this may be subject to change at short notice.
(4) It is important to have systems in place to manage referrals to secondary care. Hospital departments may have been previously closed and there may be a backlog of referrals that they will need to address. If patients were referred previously but cannot be seen, are they still on the department’s waiting list, or will they need re-referral? It is important to have a process to ensure that patients don’t fall between the cracks. You should also ensure that you know what happens with new referrals. It would be helpful to develop a ‘tracker’ system, so that you can be sure that patients referred do get seen. Involve the patients too and ask them to let you know if they haven’t heard from the hospital by an expected date.
(5) You may receive letters from secondary care, advising you that your patients have either been discharged from the clinic, or alternatively have failed to attend their appointment. These letters should be reviewed by a clinician, as they may require action. For example, if they have been discharged from clinic, have you been asked to continue the monitoring of the patient? Perhaps you have been asked to undertake six-monthly PSA blood tests or have been asked to refer the patient back under certain circumstances. Now would be the time to put in diary dates and recall systems to ensure that patients are reviewed appropriately. Does the patient realise that they have been discharged or does an action plan need to be discussed with them? If the patient did not attend an appointment, is there a reason for this? They may have been unwell or perhaps they are hesitant about attending hospital at the moment.
(6) Best practice is that test results come back to the clinician who requested the tests. However, there may be instances where a test was requested in secondary care and that service is temporarily no longer available. If that is the case, the test result is likely to come back to the patient’s GP. Once a test result arrives in your practice, even if you did not initiate the test, you do have some responsibility to ensure that any necessary action is taken. If you are unclear who requested the test, ask the patient. If a specific consultant has requested the test, even if they are no longer seeing patients in clinic, remember you may still wish to ask them for advice on any action required.
(7) It is essential during this unusual period of healthcare provision that clear channels of communication remain between primary and secondary care. Remember that, even if hospital consultants are undertaking telephone clinics remotely from home with patients, they can still be contacted for advice. Ensure that you have up-to-date email addresses and telephone numbers for consultants, especially those with whom you regularly share a patient’s care. You should document any discussion you have with your secondary care colleagues in the patient’s medical record.
(8) Certain patients are likely to be under formal or informal ‘shared care’ arrangements. For example, patients under the regular care of a rheumatologist may have their methotrexate prescribed by their GP but their monitoring bloods undertaken at the clinic. A patient receiving chemotherapy at the hospital may have their bloods regularly checked at their GP practice. A patient on lithium may require regular blood monitoring in primary care, and their hospital review may either be in person or undertaken remotely. The normal arrangements may have been changed out of necessity during the COVID-19 pandemic. You should ensure that the patient continues to be monitored appropriately, even if certain aspects of their care are having to be delivered in primary care. Undertaking a search of particularly high-risk patients, perhaps by searching for patients on particular medications, will identify those patients that could potentially otherwise be at risk.
(9) Although this article’s main emphasis is on effective communication between primary and secondary care, it is essential that you talk with your GP colleagues too, both in practice and also in neighbouring practices. You should share any difficulties you may have had relating to the interface between primary and secondary care and, importantly, discuss any potential solutions to the problems. The ICGP webinars have been hugely helpful in allowing GPs to connect weekly and learn together; this may also be an effective forum to explore the challenges that GPs face when secondary care has undergone – and may continue to undergo – change.
(10) Learning from adverse events is important and if a patient comes to harm, you should ensure that you discuss this within the practice as a team, involving clinicians and, where relevant, administrative staff too. You should identify how and why something went wrong, whether any action could have been taken to prevent the adverse event, and what action you need to take to prevent a future similar incident. You have a duty to be open and honest with patients when things go wrong, and you may wish to inform them of any changes you have made in your practice systems. Don’t forget to involve secondary care in any discussions, where their processes may have contributed to the problem.
There is no doubt that we are in challenging times. However, with recognition of what could go wrong, learning from what has gone wrong and by taking all possible steps to ensure effective communication at the interface between primary and secondary care, you will be able to minimise any extra risk to patients during the ongoing pandemic.