John Garner: Bridging the great divide between hospitals and GPs

Published on Monday 16 March 2009 18:59

I WANT to write about communication. This has been triggered by a couple of recent events: the publication of the British Medical Association (BMA) document The Way Ahead, and a number of letters I've received from doctors about patients that include mild criticism of a fellow doctor.

The BMA document is about the future direction of general practice in Scotland. It identifies six areas of concern and invites comments from the public and professionals. Now that the problems have been outlined, the difficulty will lie in finding solutions that don't require substantial swaths of money.

It is, of course, right to have a vision and strive to improve the care of the public, but much of the resource will have to come from capital currently spent on hospital services. Sadly, with the way our hospitals are funded, this is not easy.

The problem at present is that communication between hospital services and primary care services is failing, and the "sniping" letters are symptomatic of this poor communication.

There are a number of reasons for this.

First, health boards are focused on hospital services, because that is where the vast majority of their budget is spent. Little consideration is given to primary care, because it is viewed as a number of self-employed individuals who are impossible to manage. Hence the neglect.

Secondly, as the new contracts for hospital consultants and junior medical staff has quite correctly been limited in the number of hours they can work by European working time directives, there is little time for engagement between clinicians in hospital and primary care.

In the past, local consultants and GPs who shared patient care met to discuss medical issues of mutual importance, thus building respect and understanding of each of their contributions. Now medicine has been centralised, it is harder to build relations with consultant or GP colleagues; we don't know what each other looks like, never mind what each is thinking.

Indeed, it is the patient who is in the privileged position of seeing both the hospital doctor and the GP, and their remarks about poor service now remain unresolved because of the dearth of communication between the groups of doctors.

Another area that I believe is as a direct consequence of the poorer knowledge of each other's capabilities is my impression that many more intra-departmental referrals are being made.

A patient goes into hospital for stomach problems, and he complains of a rash and a persistent cough. Instead of referring back to the GP, it often generates two new referrals to a consultant dermatologist and a chest specialist, so increasing pressure on stretched hospital-based resources.

Of course, solutions are not easy, but there are some relatively cheap options that would facilitate better communication between hospitals and primary care.

Some already happen. For example, most new junior doctors now spend time working in primary care, so learning what is deliverable in that arena.

But I believe more could be done. I think all senior doctors, both consultants and GPs, should have their photos on health board websites. Then all, including patients, could know with whom they were communicating.

All GPs and consultants should have personal voicemail or e-mail, so that messages can be sent quickly without trying to get through switchboards or GP receptionists.

Health boards could also set up a series of "meet and greet" sessions to facilitate dialogue between the sectors.

Perhaps if we address communication, we won't get governments offering to pay GPs bonuses for reducing hospital referrals (as in England) and we won't get consultants complaining about the "revolving-door patients". We can only hope!

After mentioning health board websites, I took a quick look at NHS Lothian's. My practice address and postcode was wrong, and when I tried to contact the relevant manager, the e-mail address given on the health board's website didn't exist. It seems everyone needs to do better in communication.

&#149 Dr John Garner is a member of the BMA's Scottish Council and a practising GP.