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Communication issues

Coalface tales

James Booth

Monday, 15 July 2019

AdobeStock_215069286_communication_blog.jpgSomething happened this week which is becoming a bit of a rarity. I managed to speak to a consultant colleague about a patient over the phone. It was about the most useful 10 minutes of the week; I learnt some things, she had a new insight into a difficult situation, and we finished up with a sensible plan. It felt, to be honest, very much like primary care should be, and what a consultant is for.

However, this conversation happened only after I called a secretary (not the consultant's own, one shared), then called back on a day they were working, then left a message, then had a call back from another secretary, who suggested I use our local advice email thing, to which I said, no, this is tricky and need a conversation, which followed a degree of telephone ping pong over several days. That 10-minute conversation took several times as long to set up. I'd have given up had it not been for the scenario being rather unusual. 

It has made me think about just how many barriers to effective communication we have in the NHS, and surely the interface between primary and secondary care is the very place where we find the most egregious examples. Examples locally to me include the emergency service which involves: call hospital switchboard, they page nurse on call, nurse on call takes message, goes off to find doctor on call, and then relays advice, we then fax a letter to her, she rings the patient. There's the service (I won't name it, but it rhymes with "dental wealth") where you ring a number, then they work out which bit of it your patient uses, then you try and find someone in that office, and fail miserably. We have an email advice system which is fine for simple queries but doesn't allow conversation. I still have a Consultant Connect app on my phone which isn't connected to anything. We STILL haven't been able to use completely bin the fax and - this one is still the apogee of ridiculousness – why, oh why is the third largest employer in the world, in the fifth wealthiest nation STILL USING PAGERS?

It wasn't always this way. I'm not one for romanticising the past but I was talking about this to my now newly retired GP father this week. When he was at the point I am at now, he knew all the local consultants, he had their office numbers, they each had their own secretary, and they spoke all the time. Some of them even did domiciliary visits with him! Our local trust has now enlarged to the point where I now know maybe a dozen consultants by name, and many of them are nothing more than a name on a letter. We are all facing an ever-increasing degree of demand and complexity in patient care, but this has driven a change in how we interact. The ever sheer volume of admissions leads to a system where actually speaking to the med reg is really difficult, where systems to manage patient flow are necessary but divorce us from our hospital colleagues, and changing patterns of work amongst junior teams - not of their making - now means that the commonest phrase I see on a discharge summary is "Written from the notes; I did not see this patient."

It is such a loss; lost opportunities for learning, for building local relationships, and it's so often inefficient. Who here hasn't resorted to a referral when communication that might have avoided it wasn't possible? At worse, poor communication is just unsafe, and I imagine that there isn't a doctor working who hasn't seen a communication breakdown lead to a near miss, delayed care or harm. I have worked locally for nearly 20 years, I have sat on my CCG board, and I still find the byzantine referral systems locally opaque and hard to keep on top of. If I struggle, what issues are we creating for our sessional and locum colleagues, who we all so increasingly need to rely on?

The footnote to my conversation above: I finished my conversation with my consultant colleague with her agreeing to see my patient in clinic. However, this came next:

"...the only problem is that I have no power to book directly into my clinic, it's all done via the referral service and Choose and Book, so whilst I want to see her it might be hard. If you also send me an advice request into the system, I might be able to arrange something, but I can't promise." So, after all that effort, we might not manage that plan as we hoped. I also hadn't, in my naivety, appreciated quite how little autonomy our hospital colleagues have.

I don't know how much longer we have Matt Hancock as Health Secretary – a bit longer, now he has missed that other job he fancied - but the MP with his own app is clearly a massive fan of new and exciting ways for us to talk to our patients using the white heat of technology. I wonder if it has even occurred to him that helping us talk to each other might be every bit as important, and valuable to an efficient, effective health service?

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James Booth

James qualified from UCL in 2002 and has been a GP partner in Chelmsford since 2006. He is also the named GP for Safeguarding Children locally. All views expressed are his own.
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