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NHS England issues safety alert over fears about discharge reports

NHS England has been forced into issuing a patient safety alert informing GPs of around 10,000 incidents it has identified of poor communication from NHS Trusts when discharging patients to primary care, some of which put patients in danger of serious harm or even death.

The alert says that all NHS organisations should identify any work they have done to improve communication and appoint a lead to develop and share the protocols, which will be used as part of a national project to develop good practice guidance.

It follows an NHS England report last week that identified 10,000 patient safety incidents related to patient discharge, and poor communication at handover was identified as a major risk in 33% of those incidents.

GP leaders have said that the have had concerns about the quality of discharge summaries for 20 years, but the move by NHS England demonstrates the severity of the situation.

Pulse reported last month that a University of East Anglia-led audit of 3,400 discharge summaries sent to GPs in Norfolk found that 33% of handwritten summaries, and 25% of electronic summaries failed to meet NICE’s minimum clinical communications standards.

The alert warns problems like these are threatening patient care.

It states: ‘Review of these incidents identified that patients are sometimes discharged without adequate and timely communication of essential information at point of handover to all relevant staff and teams in primary and social care, including out of hours, and that information is not always acted on in a timely manner.’

‘This can result in avoidable death and serious harm to patients due to a failure in continuity of care as well as avoidable readmission to secondary care.’

The alert cites one incident where a patient was discharged with end stage Fibrocystic lung disease, but the fax to the GP and CCT said the patient had had a groin biopsy wound. It failed to mention that the patient required end of life care, or recommend end of life drugs or DNR arrangements.

NHS England has said that all NHS organisations should now identify any work they have conducted to improve communication at patient handover, and identify a lead who will liaise with NHS England on developing and sharing these discharge protocols.

NHS England will then use this information to develop national best practice recommendations and resources to improve communications and safety at handover.

GP leaders have welcomed any steps to create a coherent national framework for discharges, but argue the issue has existed for decades and that more needs to be done to make consultants accessible to GPs.

GPC deputy chair Dr Richard Vautrey told Pulse: ‘It would be good if a single organisation like NHS England can develop some standardised way of ensuring that there is timely flow of information from hospitals to practices, it’s usually that way round which causes the problem.

‘But what we want to avoid is any form of witch-hunt, what we’d want is some clear and robust encouragement to ensure that information is flowing in a timely way, and it’s as user friendly as possible.

‘GPs often find they’re having consultations with patients, who have been discharged, and they haven’t got the necessary information or it’s incomplete. That does cause problems, it’s a well-known issue and it has been for the past 20 years.’

He added: ‘We need to see far more collaboration between hospitals and general practice, and a freer access to consultants either on the phone, or on email. Easy access and rapid responses.’

Dr Mike Durkin, NHS England director of patient safety, said: ‘The alert is intended for all health care providers including general practitioners. Although compliance is voluntary for primary care we strongly encourage general practices to support this programme by helping us build a national picture of current practice and challenges relating to communication during handover at the time of discharge from secondary care.’

‘GPs can contribute by completing a short online questionnaire, a best practice template and by registering to take part in future webinars and other elements of the programme that may be of interest.’

Readers' comments (10)

  • If it takes 20 years to change things..........

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  • In other breaking news NHS England have issued an alert that smoking is bad for your health and asbestos should not be used to stuff childrens' toys...

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  • Them woods are full the bears need to releive themselves somewhere else!

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  • This is not breaking news - GPs have been hilighting this problem for years and to date nothing done - However to be fair our CCG is trying to improve the situation locally but yet to see improvement

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  • It must be state the bleeding obvious week.
    1) ccg's have conflict of interest which is poorly managed - who would have thought that would happen when CCG's were created. No GP that works in the system...shock horror.
    2) discharge summaries are awful and dangerous for the patients - really? never though that would happen. i'm sure we can sort it out with simple use of webinar and spending more time reporting it to some anonymous website
    3) patient demand is outstripping supply
    4) there is a shortage of GP's and surgeries are closing- this hasn't been something that has been worry for the last 3 years..the list goes on.

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  • Finally but will it make any difference....NO...one we had was for an ear infection that had an xray that showed a fracture in the toe!!!!!! I know they are busy but so is genral practice...

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  • Some how it's got to be the GPs fault !!!

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  • Vinci Ho

    As a witness of this 20 years history, I can conclude successive governments paid no attention on this matter as well as drifting hospital consultants and GPs further and further away from each other .
    The so called integrated care (primary and secondary care)is always a fantasy , pie in the sky.....

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  • Last year I had a discharge report which hid the fact I'd been diagnosed with Addison's Disease from my GP (compounded by my not being informed personally).

    Two weeks ago - same hospital - I got another so confusingly written that it's positively hazardous. Deeply unimpressed - change is very badly needed.

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  • We tried to change this at the inception of PCGs.
    A box to highlight what needs doing by the G P , to be faxed if urgent.
    Another for the shared care team.
    Followed by the pages of detail that no one reads
    Why no progress in 23 years?

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