Continuity of Care

This section of the website is to share news and updates about various projects and issues which are going on which relate to communications and transition of patient care.  It will be regularly updated.  Do please add any (polite) comments/thoughts you have that you’d like to share, or disucss.

Topics so far covered in this section include

Junior Doctor Induction sessions     

Our aim is to have a GP presence at every new doctor induction session within the Acute Trust. Excellent induction sessions for Junior doctors already exist within the Trust and are led by the director of post-graduate education (formerly David Macafee, now Ian Hunter, both consultants at the Trust). There is good emphasis on the importance of timely and high quality discharge summaries, but these letters are very time-consuming for the juniors who have no protected time for them and are being constantly interrupted with more pressing clinical duties.

We have developed an 10 slide summary to share with junior doctors, explaining what and why certain information is important to GPs, and how they can help us help plan the transition from hospital to home more smoothly, for our patients.

New Hospital Doctors Induction Presentation

It is also hoped that a GP presence at these induction sessions will help forge better bonds between primary and secondary care as these new doctors progress through their careers. The main date for induction is August, but there are also monthly ‘hop-on’ sessions the first Wednesday of every month.  If you would like to observe one of the Trust inductions sessions to see just how good they are (they really are!) – or if you’d like to take part in the GP rota training at these sessions, then please contact
The more GPs we have on the rota – the less onerous the committment!

Discharge letters

A patient’s admission to hospital is journey – often turbulent, traumatic and emotional . Discharge letters should be a concise and accurate reflection of that journey – without the need to endure a detailed novel sharing every minute detail.

Don’t bury the headline!
When feeling exhausted at then end of a 12-14hr day at work, how would you like to hear the outcome of The Titanic’s maiden voyage?  The three and half hour movie may contain all the emotional highs and lows, but please, just throw us the headline and main outcome.
There are many recurring themes around discharge letters which equally frustrate all parties:

  • No identifiable Consultant (Dr Z Unk)
  • Incorrectly addressed GP
  • Lack of consistency between GP systems
  • Too much / Too little information
  • Inaccurate diagnosis
  • Clarity of medication – stopped (why?) /started (why?)
  • No clarity of follow-up responsibility
  • Death discharge summaries

Problems faced by the junior doctors completing these are many:  the time each takes, interruptions, other clinical tasks which take priority etc etc (we are all far too familiar with these lists). GPs in South Tees and North Yorkshire now have access to all results on webICE should we want them – so we only need the significant ones bringing to our attention. From the Trust perspective an electronic system that self-filled admission/discharge details would help, as would ring fenced time to complete these safely and accurately. Over the next 12 months we plan to work closely together with the Trust and the LMC on this. We will keep you posted of our progress. If anyone has a passion to become involved, please let us know at

Referral letters and Clinic replies
  • Quality and content of GP referral letters
  • Compulsory standard referral templates?
  • Hospital reply letters to the named referring GP
  • Arranging follow-up tests or ‘chasing’ results
  • Making clear if patient has been advised to initiate contact with the GP to discuss follow-up plan
 Prescribing issues
  • Hand written out-patient prescription requests
  • Unlicensed or specialist medication requests (patchy GP co-operation confusing for consultants and patients)
  • Urgent same day “new medipak” requests
 Non-Clinical and Clinical Points of contact

Departmental clinical directors are possibly the most appropriate point of contact for any general, non-clinical issues about particular services.

For clinical advice, we are considering use of C&B as a more formal ‘advice’ portal where phone/letter may not be appropriate or easy. More to follow.

Out-Patient appointment system

The Trust are looking at an overhaul of the outpatients appointment system and are consultant patients, staff and GPs views on this. In May 2016,  representatives from the Acute Trust asked GPs to comment on what aspects of the OPA system they felt worked well and which they felt could be improved.

In summary – the main recurring themes are listed here and a link to more detailed individual responses is at the bottom:

Administrative burden
DNA vs cancelled appointments and the subsequent mess – including demand for GP re-referrals
Chasing up appts because of extensive delays in receiving both new appts and f-ups
Letters arriving after the appt date
Chasing up letters – sometimes 6-8wks later.
Letters being addressed back to the referring GP – saving us having to redirect them in house.
C&B rejections.

Safety issues
Quality and timeliness of correspondence –
Out-patient prescribing and transfer of Px advice (frequently illegible)
Delay in appointing routine and urgent slots (as becoming more pushed back due to 2week rule referrals)
Following up investigations done in secondary care

Clinical burden
Prescribing, sick notes, and hospital investigation follow-up requests
Consultant-to-consultant onward referrals issues – Needs clarification. (Suggestion: 1. Same problem/symptom following a NICE management pathway —> Allow C to C referral. 2. Onward referral of 2week rule or new urgent problem discovered —> Allow C to C referral. 3. Incidental other problem (non urgent) —> ask patient to see GP who will manage and decide as feels most appropriate)
Prolonged, drawn out approach to multiple hospital investigations – requiring repeat appointments, and GPs to bridge the ‘anxiety’ gaps.

Also – theTrust offers many clinics which are great asset to us and patients are poorly advertised.

Detailed responses from individual GPs here:
Outpatient feedback consultation

* * *

If you would like to add your own comments/thoughts to any of these issues  (or others) please let us know or add your comment below.



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