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 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
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