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At the heart of general practice since 1960

Hospitals will have to take responsibility for patients after discharge

Dr Andrew Green

As a GP you learn to be un-shockable, but when some years ago I was at a local meeting discussing handover of patients from hospital, I was genuinely shaken by the chief executive saying that ‘our responsibility to the patient ends at the hospital door’. So when the opportunity came to work with NHSE to prepare some standards for safe handover of test results I jumped at the chance. I saw this as an opportunity to end patients coming to us for their results, to end results being lost between hospitals and GPs, and to end those words at the end of a letter: ‘GP to chase…’

The intention of all involved was clear, to lay down standards that placed patients at the heart of the process

On Monday, these standards were published. The GPC had already done the groundwork for this through our agreement with consultants, and this document builds on that work by placing pressure on the managers within secondary care to set up systems that allow these measures to be implemented, regrettably they were never likely to be influenced by our clinician-led statement.

There are clear challenges in producing a collaborative document, but the intention of all involved was clear; to lay down standards that placed patients at the heart of the process, ensured their safety, and placed clear obligations on those requesting tests to take responsibility for follow up.

The principles

The first is that the clinician who orders the test is responsible for reviewing, acting and communicating the result and actions taken to the GP and patient even if the patient has been discharged. 

The second is that every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test.

The third is that patient autonomy should be respected, consideration given to reasonable adjustments for people with learning disabilities and mental health problems and, where appropriate, families, carers, care coordinators and key workers should be given the opportunity to participate in the handover process and in all decisions about the patient at discharge. Use of interpreter services should be considered if the patient doesn’t speak English

From NHS England, Standards for the communication of patient diagnostic test results on discharge from hospital

The most important part of the document is the first principle, which clearly sets out the hospital’s responsibilities, and which is at the heart of this debate. The second simply lays out existing practice professional obligations, those who read, post or see results have to have the ability to understand them, and you cannot ‘unsee’ a result that has implications for a patient. This does not provide an open door to random copying of results to GPs, on the contrary, it provides GPs with the tools they need to stop this practise, as hospitals only behave in this fashion because they believe it fulfils their responsibilities; it does not

Of the eight standards, standard five (which previously read: ’Where a consultant delegates responsibility for any tasks around the communication of diagnostic test results to general practitioners, they should ensure clinicians given the task understand and fulfil that responsibility’) has raised concerns, with the ‘delegation’ being interpreted as being from consultants to GPs. However, this is not the case, as it refers to delegation from consultants to juniors, so this standard should ensure that junior doctors understand their obligations. This interpretation has always been clear from the accompanying explanation, and soon will be clarified in the document on the NHSE website.

I am aware that some areas already have functioning systems in place, nothing here undermines those existing agreements, and indeed the document does stress the need for local arrangements. I hope that LMCs in areas where systems are not working properly will see this as a resource that they can take to their commissioners and secondary care providers to ensure they fulfil their obligations, and that it will empower individual GPs to resist individual examples of bad practice when they are encountered. Dr Chaand Nagpaul, BMA GP committee chair, will be writing personally to LMCs and CCGs to provide support for this process.

Dr Andrew Green is a GP in Yorkshire and chair of the GPC Clinical and Prescribing Subcommittee

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Readers' comments (5)

  • I wonder who that chief exec was?

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  • Thank you for this clarification, Andrew, and for supporting the revised wording of Standard 5. As I have remarked on the news story on this site today and in my tweets to you, I remain concerned that this document may be used to achieve an effect opposite to that which you intend.

    The second guiding principle ("Every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test.") sounds like a sensible safety net. However, how is the GP to know whether or not the result of a test they did not order has been acted on by the requestor? Equally, how can the requestor of any test know that the GP is competent to act on the results of a test that they might not be familiar with?

    Similarly, Standard 7 ("Appropriate systems and safety net arrangements should be in place in primary and secondary care to ensure any follow-up diagnostic tests required after discharge are performed and the results are appropriately fed-back to patients.") opens up potentially unsafe ambiguity about the responsibility of post-discharge tests, especially if discharge summaries are delayed. I am sure every GP has received a discharge summary advising blood tests to be carried out BEFORE the discharge summary actually reaches the GP!

    GPs should not be the default safety net for everything. Requestors of tests should retain responsibility for arranging them and actioning the results and should ensure that they maintain reasonable safety nets.

    GPs are not community house officers. If a hospital doctor has made the decision that a test, prescription or referral is required, they should arrange that. If, on the other hand, they believe that the opinion of a GP (who is well placed to know what can be arranged in the community) would be helpful, they should advise the patient to consult their GP on a routine basis after the discharge summary or clinic letter has been received by the GP.

    I fear this guidance actually INCREASES the risk that post-discharge tests will not be arranged or acted upon by introducing ambiguity in responsibility. BMA guidance in this area is much clearer tinyurl.com/dutytestprescribe and should stand.

    For ease of reference, I have also published these remarks on my blog at http://www.drcosgrove.net/2016/03/nhs-england-test-standards-increase-risk.html.

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  • 'The second guiding principle ("Every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test.") sounds like a sensible safety net. However, how is the GP to know whether or not the result of a test they did not order has been acted on by the requestor? Equally, how can the requestor of any test know that the GP is competent to act on the results of a test that they might not be familiar with'

    I agree completely. This green-lights work-dumping by 2' care.

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  • Hospitals order tests done at our treatment room. The bloods land in my inbox. What do I do with what appears to be strange results ?
    A GP in NI was sued because he misinterpreted a test ordered by a Consultant that landed in the GPs inbox. We GPs cannot be specialists in everything, but no one defines the limits of our knowledge.
    Therein lies mistakes and litigation.

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  • There should always be a consultant /GP telephone dialogue when ever test results or management plans (or whoever will act on it) are unclear to either party. This should also include the patient.

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