Intended for healthcare professionals


Communication between GPs and cooperatives is poor for terminally ill patients

BMJ 1997; 315 doi: (Published 08 November 1997) Cite this as: BMJ 1997;315:1235
  1. Stephen Barclay, Macmillan general practice facilitatora,
  2. Margaret Rogers, PhD studenta,
  3. Chris Todd, Directora
  1. a Health Services Research Group, General Practice and Primary Care Research Unit, University of Cambridge, Institute of Public Health, Cambridge CB2 2SR

    Editor—In a study of a general practice cooperative, Salisbury pointed out that pressure for change in out of hours care has come almost entirely from the medical profession and that it is important to consider the patients' perspective.1 Our work has identified that continuity and familiarity of professional carers are particularly important to terminally ill patients in the community.23

    By looking at medical records, we undertook a retrospective audit of palliative care in the Cambridge general practice cooperative, which covers 210 000 patients. During August 1996 there were 2202 patient contacts, 53 of which were for 40 patients recognisably in the terminal phase of their illness. Forty three visits (including 10 to certify expected death) and 10 telephone consultations were made.

    Three areas of discontinuity of care were identified. Firstly, none of these patients' general practitioners had handed over any information to the cooperative. In each case the cooperative doctor was managing patients close to death, or meeting newly bereaved relatives, without any knowledge of the physical, psychological, and social backgrounds. Secondly, continuity of care within the cooperative was lacking. Six patients had two contacts with the cooperative, two had three, and one had four (13 repeat contacts altogether); only one patient saw the same doctor twice. For nine of these 13 repeat contacts, the cooperative doctor was unaware of information from previous contacts with the cooperative. Thirdly, rapid handover from the cooperative to the general practitioner was patchy. While details of all deaths were routinely faxed to the general practitioner the next working day, this occurred for only half of the telephone contacts and visits for dying patients; for the remainder, the general practitioner was informed by post.

    The loss of personal continuity of care may be mitigated by the general practitioner handing over information concerning vulnerable patients to the cooperative, by ensuring the communication of relevant information within the cooperative, and by routinely faxing details concerning dying patients to general practitioners; it is planned to introduce these changes locally. Currently available computer programs could readily facilitate such communication, thereby maximising continuity.

    The Cambridge cooperative has established a good reputation overall but seems not to function well with terminally ill patients, who constituted a small but important part of its workload. If primary care is to remain central to palliative and terminal care,4 every effort must be made to minimise the adverse impact of the recent changes in out of hours care.


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