Hospital takes two months to tell you patient has heart failure
Three GPs share their approach to a practice problem
You have been unhappy for some time about letters from the local hospital being delayed and by peremptory 'requests' that you, rather than the consultant, should act on MSUs, blood tests and other investigations for patients treated both as in and out-patients. Today you get a letter about an X-ray taken at medical out-patients two months previously, which shows your patient, whom you have not seen for months, has cardiac enlargement and bilateral pleural effusions.
The specialist registrar tells you that the most likely cause is heart failure and says she would be grateful if you could change his treatment from a thiazide to a loop diuretic and repeat his chest X-ray in due course. Oh, and by the way, she adds, 'as he has not had a diagnosis of heart failure before, I would recommend that you request an echocardiogram as an out-patient'.
1. This is very bad. Treatment request based on a two-month-old X-ray? A seriously abnormal X-ray ignored or missed or mislaid for two months? Loop diuretic and out-patient echocardiogram? Is it really best or even average practice to treat congestive heart failure with nothing more than a loop diuretic? What about an ACE inhibitor, ß-blocker and statin? And finally, it seems no GP has seen the patient in the interim!
This is, sad to say, very poor practice by the hospital staff. The patient needs care first so I'll get him in for review. Then I'll write a note to the consultant, as outlined above, expressing my concerns. But of course this is only the latest in a series of events that certainly puts patients at risk so I have more work to do, preferably with my LMC. The other problems of late letters and failure of hospital staff to follow up abnormal results could be any or all of: a general systems failure in the hospital; consultant arrogance; consultant ignorance; secretarial understaffing; a misguided belief that GPs want to take on more follow-up; and jealousy of GPs with allegedly high earnings and no night work. Is this a 'failing' hospital? Is there much communication between GPs and consultants, whether in formal committees, lunchtime meetings or just phone calls? Is there any communication at all between GPs and non-consultant medical staff? If it is just one consultant or one department, pinning down the problem is easier, but regardless this needs a formal and well documented approach, probably via the LMC. I shall inform my defence organisation also because if a patient suffers harm I may be held partly culpable. I know there is a big problem and I must be seen to be doing something about it. I may even have to set up a system for reviewing patients after visits to out-patients.
Declan Fox is a GP in Newtown-stewart, Co Tyrone, and a writer, teacher and broadcaster
2. Historically many consultants have treated GPs either with disdain and less respect than their pre-registration house officer or, alternatively, sycophantically, doing all they can to win private referrals. Hospital investigative departments have treated their results service as their own fiefdom. Many have worked hard to humiliate GPs into begging for an MSU on Mrs X or a chest X-ray on Mr Y, then refuse to release the result because a hospital doctor ordered the test rather than the GP.
All this is set to change. IT is opening access to all results. With confidentiality provisos any hospital that refuses full access to results on their patients is likely to disappear. It will not be many years before our screens display the most recent consultation note on a patient regardless of where in the NHS they were seen, and any clinician will be able to pick up on outstanding results. With these radical changes the entire raison d'être of secondary care is facing a massive overhaul. Unless a clinician has an intervention that can only be delivered in a hospital (such as surgery), they will find it hard to justify their continued secondary care status. GPs will be making direct referrals for investigations and procedures and the patient sitting out his afternoons in out-patient departments complaining about the local health service will be a relic of the Carry On films. At present our practice employs two people whose sole function is to chase results, reports and appointments for follow-ups and investigations. This drain on resources is completely outrageous, but to sustain patient care we have to fund it. The biggest advantage is that I no longer lose my temper with incompetent or deliberately obstructive personnel in secondary care or other agencies. These staff are also well rehearsed in the lines to use depending on levels of obstructiveness. One that works a treat is: 'failure to deliver the simple test we are requesting raises serious clinical governance concerns regarding your department, which we must consider reporting to your medical director and if necessary the GMC'. It's heavy, but it never fails. If a delayed result like the one in the scenario were to drop through our door with serious abnormalities that should have been flagged up earlier we would have no hesitation in filing a complaint.
Nigel de Kare Silver is a GP trainer in north-west London and a course organiser
3. Both delays in receiving hospital letters and repeated requests for hospital results to be actioned in primary care are frequent irritations in general practice. As always the patient's best interests must come first.
I would ask the patient to come and see me as soon as possible. I would read the letter with them and explain what the registrar is suggesting. I would examine the patient, then discuss with them possible changes to their medication. I will be responsible for a prescription even if the medication is suggested in writing from the hospital. It may well be sensible to change the thiazide to a loop diuretic but the patient might also benefit from an ACE inhibitor, spironolactone and even a ß-blocker. The patient's U&E will need monitoring. If I have access to an echocardiogram I would organise one as soon as possible to confirm the diagnosis. What I would do about the irritations of delayed letters and requests for results to be actioned will depend on my energy level and state of mind. I might do nothing or I might try to address the issues in a constructive way by writing to the consultant concerned. I will have to write to them anyway if I do not have access to echocardiography or if I feel managing this patient is out of my depth. If this is a widespread problem it might be worth collecting evidence from auditing letters, and taking it up with the clinical director of the hospital trust or the PCT.
Following up abnormal results
• Responsibility for following up an abnormal result usually rests with the person who organised the test. So requests from secondary care to follow up their abnormal results are asking you to take over this responsibility. It is your choice whether you do this or pass that responsibility back to secondary care.
• Sometimes it is patently more convenient for your patient if you follow up a result – for example, when an MSU result arrives back after a patient is discharged. On other occasions it is not appropriate for you to take on this responsibility.
• Fail-safe systems are quite widely employed in primary care to make sure abnormal results are conveyed to patients. Patients can be advised of what tests they have had done and advised to check on the result themselves after an appropriate interval. The practice may then mark results that have been discussed and chase up those that are abnormal where patients haven't been informed within a set period.
• Can secondary care providers demonstrate equally robust systems?Shifting work from secondary care
• Direct access to a wide range of tests and rapid availability of results allows a wider range of conditions to be managed in primary care without referral.
• It also allows outpatient clinics to discharge patients after performing only some of the necessary investigations.
• In some instances it is the way in which services are commissioned, by limiting follow-up visits and not allowing cross-referral in hospital, which encourages this situation.
• I would argue that the consultant is being treated like the GP's lackey, simply being asked to perform a specific test and not get involved in the patient's overall management.Managing increased workload in primary care
• This patient illustrates the workload implications in shifting care. He will need investigations organising, phlebotomy time, nurse time for review and education and frequent changes in medications.
• There may be knowledge and skills gaps for GPs that can only partially be addressed by protocols and software to aid decision making. How good are protocols in managing frail elderly patients who live alone and have two other concomitant conditions?
• Specialist nurses such as heart failure nurses can support the practice team and help develop local protocols.Complaining about services provided by secondary care
• The patient has the right to complain and may ask for your advice.
• For isolated complaints about a specific patient, gathering the facts, discussing them with a colleague then phoning the consultant to discuss your concerns might be reasonable.
• Where complaints are part of more general dissatisfaction, the LMC should be involved. This allows evidence to be gathered for formal discussions.
• The PCT and practice-based commissioning groups are also in a strong position to negotiate contracts outlining the boundaries of primary and secondary care and setting standards for communication.
Richard Stokell is a GP in Birkenhead, Merseyside