Observations Life and Death

Falling through the gaps in care

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7863 (Published 21 November 2012) Cite this as: BMJ 2012;345:e7863

Re: Falling through the gaps in care

A further Response to Iona – It needed to be mulled over.
“Falling through gaps in care”

The discussion regarding the gap between the beds in the acute specialist hospital and home begs the question about another notable gap. If we are interested in continuity of care and wish to develop community beds because of this perceived gap in care then, are we happy with the gap which exists within primary care between in hours and Out of hours care? It behoves us to first remove the mote in our own eye.

The pride we have in our Primary care now appears focussed on a service which has become increasingly office based, limited to the in hours period and some would say in focus. Out of Hours the value of the primary care team, continuity of care and the centrality of the record suddenly appear to become less significant and subsumed by other needs. With the turn of the clock we move from one team to another providing the care within the community to which Dr Heath refers and the further complementary services to which she aspires. With limited experience it appears to me the connections are tenuous between one system and the other. Out of Hours providers have obligations and quality standards against which they are measured defining the communication to in hours services. There are no such standards for the information handed over to the Out of hours provider by practices although there is indicative guidance regarding patients with “special notes” and Care summaries for Palliative patients.

So with limited information regarding the patient record and a doctor light service what do we expect from our Out of Hours service. Are they part of the system? Do they just “hold the ring” until the “normal”, for that read “proper”, doctor comes back on duty? Is this about emergency medicine or an “open all hours”, 24 hr. walk in service? I am not certain we know what we want never mind what we have. I am certain most patients have no idea what the service is for and what the relationship is with primary care in hours.

We need to review this situation either as a whole or the relationship between the Out of Hours services and the other health & care services as it appears that in areas they are orphan services which work in isolation from both the primary care and the hospital services. This is not to denigrate the good work done by many of the services which are often praised for their willingness to see almost every patient, whatever the problem, whatever the time.

However we have moved from a system which had the GP as the central decision maker regarding clinical care issues in the community to a doctor light system which inevitably is more centralised and has a lower profile with patients. This results in increased attendances to Accident & emergency units and calls to the ambulance service via 999 often by call centres. Then we have the reactive behaviour from these agencies trying to ensure they only see patients with acceptable problems.
Developing and maintaining community beds thus has implications for other services. For more than half the week they will not be likely to be the responsibility of the local GP who does not do Out of Hours.

Even now the responsibility for community hospital medical services in the out of hours period has fallen through the gap as there are often no formal contracts for the care of patients in these hospitals Out of Hours. Contracts need to reflect the responsibilities and obligations for the whole week especially if we see the role of the community hospital as an admission unit and not as some glorified “step down” unit for community rehabilitation post admission to the acute hospital . The admission of patients means on-going responsibility for their management which may sit less easily with those who are remote and for whom this is not part of their normal practice. Some of our GP colleagues do not see inpatient work as being any part of general practice which has proved a stumbling block to the development of community hospitals in some cities e.g. Glasgow. “You can take a horse to water….” Sir Harry Burns CMO. SACH Symposium, Peterhead, October 1995.

I am sure that increasing the resilience of the community services does result in improved outcomes for the patients and the family and increased professional satisfaction. As Dr Heath says it requires support for the educational needs of the professionals and resources but it may well be more cost effective.

The consequences of the new GMS contract 2004 including Out of hours and community hospitals were predictable and well-illustrated by papers circulating prior to the changes. The vested interests were not interested. Putting the genie back in the bottle may not be possible but we need to think about what our patients and our communities need and what we want to achieve. There are other ways of organising care in our communities which would produce local solutions and increase the capacity of the community to provide holistic care but we need to be open to these possibilities. Awareness of the gaps in care is the first step of opening our eyes.

Standards for The Provision of Safe and Effective Primary Medical Services Out-of-Hours.
http://www.healthcareimprovementscotland.org/previous_resources/standard...

Quality indicators for primary care out-of-hours services
http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=348394d...

Competing interests: Prev chair SACH Prev Principal in General Practice and salaried Out of Hours doctor. FRCGP

28 November 2012
Hamish D. Greig
General Practitioner
Scottish Association of Community Hospitals
Pearsecroft, 8-10 Pearse Street Brechin Angus DD9 6JR
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