NHS discharge planning: lost for words

Put yourself in the place of the GP with patient Mrs Jones sitting in front of him. She has been poorly and been in hospital, where they did all sorts of tests and changed her drugs. Now she is a bit worried and wants to check whether she should carry on with her usual pills.

Theoretically, Mrs Jones' GP should be able to look at a discharge summary sent by the hospital and use it to help answer her questions. In practice, that is rarely the case. Successive surveys over the past three years by primary care organisation the NHS Alliance have shown that these flimsy bits of handwritten, carbon-copied paper often arrive late, incomplete or illegible (see below).

Examples of concerns raised in the 2007 survey of 500 GPs include: "Not only are we plagued with late summaries, when they do arrive a percentage of them are incorrect, some with no diagnosis and others without the patient's name. Some never arrive."

In one astonishing case of tardiness a discharge summary arrived 11 years late, although delays of three months, six months and even a year were more common.

Another GP commented: "Some hospitals send handwritten notes that are often illegible, full of ambiguous or unknown acronyms (eg "from gynae PE" - is that pre-eclampsia or pulmonary embolus?). These may come promptly - but then meaningful Dx [discharge] summaries rarely come at all - so no idea which clinic, consultant, blood test, etc."

The consequences for patient safety are clear. GPs remain ignorant of changes in the patient's medication, the results of diagnostic tests or even the fact that an admission took place and follow-on care may be needed.

The NHS Alliance cites one case where a patient was admitted to hospital for three days after an overdose of paracetamol. Although their GP had been treating them for clinical depression, it was not until 11 months later that the hospital sent discharge information and the GP learned of the overdose. Had they known, the GP would have considered reviewing medication and perhaps arranging more intensive support from a community psychiatric team. None of this could be done because the hospital left the family doctor in ignorance. Luckily, the patient lived.

There is a financial cost too. The NHS Alliance's 2008 survey states: "Staff time taken to resolve these problems has never been properly estimated, but it is certainly high. Hours can be spent on trying resolve a single case. One doctor told us she estimates that on average she spends half a day a week chasing up information that should have been available as a matter of course.

"Further costs are incurred when patients have to be readmitted [to hospital] because it has been impossible to continue their treatment properly in primary care. Again, the prevalence of this has never been investigated. In today's stringent financial climate, that is an omission that should be addressed."

This is all horribly familiar to Royal College of GPs chair Steve Field. "This comes up regularly in my meetings with GPs. They say: 'You can talk about integrated care but you cannot even get us a discharge summary.' The problem is clearly that it is not treated as top of the list by hospital staff," he says.

NHS Alliance chair Michael Dixon agrees: "It is not seen as a priority." Dr Dixon, a GP, says it is left to junior doctors to complete forms on paper, a task that many in this computer literate generation put to one side for a "quiet moment" that never seems to arrive. They must also wait for consultant or registrar approval, introducing another delay, before the form is posted. It says something about the relationship between primary and secondary care, Dr Dixon adds.

"No consultant would see a patient of mine without a decent letter and I would not expect them to. It tells me that there is an inequality here and that the acute sector still calls the shots."

But if primary care trusts start to get tough - as many GPs would like them to - acute trusts could find themselves facing financial penalties if they do not sharpen up their practice.

In 2008, prolonged lobbying by the NHS Alliance bore fruit when the Department of Health strengthened the standard NHS contract. Since April 2008, the contract has contained a national standard (but not a target) that hospitals must issue a discharge summary within 72 hours of a patient's discharge. This will go down to 24 hours on 1 April 2010.

The standard also states that when a patient is discharged they should leave the ward with a letter setting out basic information about the treatment they received and contact details of the ward or department where they were treated.

"It is unacceptable for patient safety to be compromised due to lapses in communication after a patient has been discharged from hospital. If hospitals fail to provide discharge information to a patient's GP, they are in breach of their contract and can be penalised financially," says a DH spokesperson.

PCT Network director David Stout says the move is easily within PCTs' reach (see case studies below).

"If there is persistent underperformance on this, it would be a reason for PCTs to use their contractual powers and penalise trusts financially. What will be interesting is to see the extent to which PCTs monitor this as part of their quality reviews with trusts and therefore use these powers."

But, as the NHS Alliance points out, some foundation trusts still have three years to run on their standard contract, depriving PCTs of this financial lever, although it should be noted many foundation trusts are leading the way with electronic delivery of discharge summaries.

While welcoming the contractual changes, the NHS Alliance says they do not go far enough.

"We will be pushing for the final solution, which is to make the discharge summary the payment document. So if you don't send the summary to the GP or if the coding information is missing, you don't get paid," says Dr Dixon.

Another change has been under way since a national agreement was reached last October by the Academy of Medical Royal Colleges and NHS Connecting for Health on precisely what information should go into discharge summaries.

As part of a project by the health informatics unit of the Royal College of Physicians to develop standards for structuring the clinical content of hospital admission records and handover and discharge communications, prototype standards were piloted. They were sent out for consultation to patients and families, other medical royal colleges and specialist medical societies. Work is under way to incorporate them into patient administration systems to be supplied under the national IT programme (see case studies below).

Dangerous period

Connecting for Health clinical director Professor Michael Thick says: "It is often observed that the most dangerous period for the patient is the handover between one clinical team and another. This work was about developing a consensus and professional agreement about what information is needed for that to happen safely and our intention is that no patient should suffer as a result of lack of information."

Although the standards were developed for use in national computerised systems, there is nothing to stop people adopting them now for existing paper based or local electronic systems, he adds.

Beyond the NHS Alliance's surveys, it is hard to gauge a national picture on discharge planning. But later this year, the Healthcare Commission is due to publish a national review of how PCTs ensure safe medicine use after a hospital discharge.

"The prescription and use of medicine in particular must be closely monitored to ensure patients are receiving the high quality care they need and deserve at all times. We will be looking at whether PCTs formally require acute trusts to provide appropriate and timely information to GPs when a patient is discharged and whether they ensure GPs update patient records and review medication on a regular basis," says a spokesperson.

The review will involve inspections at a number of PCTs identified by the commission as "high risk". The results for each trust will be published in full early this year.

So the levers for change are in place and it is up to PCTs to take a lead.

As Dr Dixon says: "Frontline commissioner power and patient power is what will change this. I hope practice based commissioning will bring commissioners closer to patients and therefore to the people who are suffering the consequences of this and that this will lead to a change."

CASE STUDIES

Performance notice gets results

After Tim Riley arrived as chief executive at Tameside and Glossop primary care trust in 2006, he visited every GP practice in the patch. Everywhere he went, he heard the same thing: you have to do something about discharge summaries. His response was simple.

"We issued a performance notice." This threatened a financial penalty if trusts did not issue discharge summaries within five days in the first instance.

"As a result, our main acute trust, Tameside Hospital foundation trust, pulled out all the stops. They employed a full time manager for discharge summaries and we now have 90 per cent of discharge summaries with GPs within five days and are on course for doing that in three days in 2009."

"This was a fantastic piece of practice based commissioning," says local GP and chair of the PCT's professional executive committee Raj Patel.

"The GPs told the PCT there was a problem and it needed to be addressed. The PCT was able to broker the deal on behalf of all the GP practices."

The next step, now under way, is to introduce electronic discharge summaries. Dr Patel would like this to include coding information so they can be used as a proxy invoice.

Mr Riley adds: "We increasingly want to be able to capture electronic discharge so that we can start analysing patient pathways."

Going electronic

Birmingham East and North PCT has been working for over a year with its main acute provider, Heart of Birmingham foundation trust, on developing electronic discharge summaries. The move has had benefits for the trust as well as GPs and patients.

"We had long standing problems with legibility of handwritten documents. When we started working on this with the trust, we also looked at redesigning the document so that it would become more usable for the GP," says PCT medical director Doug Wulff. The work was done jointly between GPs and hospital consultants."

The result is a slick system in which junior staff type up discharge summaries and print a letter for the patient to take away with them. As they do this, the system generates an email to the consultant, who can review and check the summary, contacting the GP if necessary. The GP, meanwhile, also receives a notification and because they are able to access the trust's electronic patient record, they can look up the relevant information from their desk.

The system has also been linked to electronic prescribing. As a discharge summary is printed off for the patient, a notification goes to the pharmacy, which can then prepare medications for discharge.

"Patients can go home earlier and it has taken a step out of the provision of medication," says Dr Wulff.

The PCT has not yet audited how quickly GPs are getting their discharge summaries nor how complete they perceive them to be - but it plans to. Nor is the system universal across the PCT's whole patch, because Heart of Birmingham foundation trust has taken over Good Hope Hospital, where IT systems are slightly different.

"But where it is working, there has been really positive feedback," says Dr Wulff. "The really interesting thing is the way that junior doctors have taken to it like ducks to water. They much prefer to type than write."

Future proofing discharge summaries

Among the benefits expected of the Lorenzo patient administration system being developed by CSC is that it will improve discharge summaries.

Sydney Schneidman, clinical lead for health informatics and an accident and emergency consultant at University Hospitals of Morecambe Bay trust, where Lorenzo is now being piloted, is determined to deliver this.

"We are looking at a team approach to documentation," he says. Junior doctors, nurses and others will complete each patient's documentation during their time in the hospital and at discharge the relevant details will be extracted automatically and sent to the correct GP.

"Junior doctors will start to develop a discharge summary from day one of a patient coming into hospital," says Dr Schneidman.

In addition to going out to the patient's GP, the summary will also automatically go to the consultant or registrar for review. "GPs will receive a draft form and it will arrive with a draft watermark on it," he adds.

Software developer iSoft is now building in the joint standards on information sharing recently agreed by the Academy of Medical Royal Colleges and NHS Connecting for Health. Dr Schneidman is working with CSC to ensure no data is lost in the workflow and with clinicians who will use the new system from early this year.

GP OPINION

The NHS Alliance has surveyed GPs over the last three years on discharge summaries. Its 2008 findings include:

• 70% - GP practices that experienced late discharge summaries "very often" or "fairly often"

• 90% - Number that said this compromised clinical care

• 68% - Number that said it compromised patient safety

• 63% - Number that said some hospital departments did provide prompt discharge summaries (2007)