GPs have considerable insight into the care that their patients receive as we are commonly the ones to instigate the acute admission. We also take over the ongoing care of our patients following hospital discharge and are therefore privy to the stories that patients tell of their hospital admissions.
Hospital care of patients
As one might expect, GPs hear accounts of exemplary care, but also many accounts of chaotic, disjointed care that falls short of patient and GP expectations. There is likely to be an entire spectrum in between, but patients probably don’t comment so much when things go relatively smoothly and care is just about good enough.
Perhaps our most pertinent reflection is that the concept of holistic care is fast disappearing. Patients are often subjected to “quick-fix” treatments, without a sense of anyone taking overall responsibility for their care needs. This is particularly concerning given the growing problem of multi-morbidity, but at the same time unsurprising given the increasing trend towards specialism and super-specialism. As a result, there appears to be a very real and evident gap in terms of what patients need and what hospital physicians are able to provide.
Hospital teams often overlook patients’ circumstances and their ability to cope independently following hospital discharge. Older patients are sometimes discharged very late at night or at weekends, without appropriate follow-up plans in place and then are readmitted shortly afterwards. A failure to look beyond their medical needs and an inability to view the patient as a person is frequently at the heart of this. GPs acknowledge that the hospital environment is not always conducive to providing person-centred care. We are aware that wards are overcrowded and noisy, staff overworked, and information about the patients’ background sparse. These factors cumulatively contribute to a sense of “firefighting,” in which the clinicians sometimes struggle to provide safe medical care, let alone have the luxury of finding out what matters most to the person and addressing this.
GP communication with hospitals
On speaking to our colleagues, there are mixed views about the ease of communication between primary and secondary care. The consensus is that communication is dependent on both systems and personalities—and that one of these cannot compensate for the other.
For GPs, it can be difficult to get through to hospital colleagues for advice and clarification. It is not always clear who the appropriate contact person is, and once that person has been reached there can be a lack of understanding about the GP’s concerns. Many hospital doctors give the impression that their priority is to prevent admissions, and do not appear to be able to put themselves in the GP’s shoes.
In our experience it is vanishingly rare to get a call from the local hospital team seeking information or advice about a patient. One colleague reported that she sometimes receives a flurry of calls inquiring about patients from foundation year doctors in their first week or two working in hospitals—but then never hears from any of them again. Our perception is that hospital teams are too busy.
In addition, it appears that hospital colleagues often don’t appreciate the wealth of information that we have as GPs. This not only takes the valuable form of the computerised GP record (which these days is generally far more comprehensive and organised than hospital records), but we also have “knowledge of the person”—a less tangible but often essential part of good clinical decision-making.
The way in which GPs work has also changed. New GPs are commonly working part-time and engaging in portfolio careers, so the provision of continuity is not as strong as it used to be. The combination of these factors makes it all too easy for things to slip through the net when patients are transferred between care environments.
Virtually all the GPs we spoke to said that the speed and (in general) the standard of hospital discharge notes had improved. Also, when hospital doctors and GPs collaborate, it seems to be a positive experience for the clinicians involved and the patient. One colleague described doing a joint home visit with an elderly care consultant and commented: “Brilliant—this is how things could work, it could have taken dozens of letters to sort out—but I’ve not seen her before or since.”
Likewise, we are increasingly using email as a source of advice from hospital specialists, and when this process works well it enables us to provide responsive care and sometimes to avoid unnecessary hospital referral/admission.
Our overall impression is that patients’ experiences of care on acute wards, and GPs’ experiences of communication from hospital staff, are variable, unpredictable, and unsystematic. We frequently hear of outstanding examples of care and communication, but also of many failures to inform—or elicit information from—patients or their GPs. The system is not “broken down” or dysfunctional as a whole. However it is clear that there are no regular standards or practices for involving patients or GPs in care, either within individual hospitals or across the secondary sector.
Rammya Mathew is an academic clinical fellow in general practice and is undertaking a National Medical Director’s Clinical Leadership Fellowship. She is currently part of a team at the Royal College of Physicians that is setting up a quality improvement hub aimed at giving health care teams the skills to improve services locally.
John Launer was a GP for 29 years and is also is trained as a family therapist. He is currently lead programme director for educational innovation at Health Education England, an honorary senior lecturer in primary care at University College London and honorary consultant at the Tavistock Clinic.
Competing interests: None declared.
A version of this article was published in The King’s Fund’s report: “Organising care at the NHS front line.“