Intended for healthcare professionals

Observations Border crossing

Who is at the helm on patient journeys?

BMJ 2007; 335 doi: (Published 12 July 2007) Cite this as: BMJ 2007;335:76
  1. Tessa Richards, assistant editor, BMJ
  1. trichards{at}

    Doctors know that poor communication and lack of continuity of care are behind many medical errors. So why aren't they doing more to coordinate care?

    Two years ago a 41 year old English journalist died from septicaemia. Her case haunts me. Two days before the Easter weekend Penny Campbell had an injection for haemorrhoids. During the weekend she became progressively unwell and called the out of hours medical service eight times. None of the doctors she contacted realised how ill she was. By the next day the die was cast; within 24 hours she was dead.

    Her case hit the headlines and continues to do so. Four months ago London's Evening Standard (14 March) used it to lambast the “costly shambles” of GP out of hours services and called for GPs to resume running Saturday surgeries. I shudder at the distress Penny must have felt and that expressed by her husband in a Daily Mail article (“The eight doctors who failed to diagnose my dying wife,” 29 May). I relate to it too: over the weekend before my father died I also made eight calls to a service with no memory.

    Five weeks ago the inquiry into her case reached its conclusion. Only one of the eight doctors was deemed to have failed to provide “reasonable” care. The problem, the inquiry found, was lack of continuity of care. Each episode was treated as a new one, and the doctors concerned had no access to their colleagues' notes. In the wake of this judgment the Department of Health has asked primary care trusts to “review their arrangements for how clinicians relay information to each other” (BMJ 2007;334:1130 doi: 10.1136/bmj.39227.482731.4E).

    Exhortations to look at what you do and do it better seldom solve entrenched problems. All health professionals know that continuity of care matters—and that it depends on good communication among those providing immediate care, timely and rigorous “handover” of information between teams, and coordination of care over time. Equally we know that the NHS is not good at providing continuity. Patients know it too, for they are constantly being asked to supply “missing” bits of their medical jigsaw.

    Not many professions manage their clients' affairs blindfolded to key information. Commercial lawyers take continuity very seriously, and not only because changes of team upset clients, who are paying a lot for their services. The same people may manage individual cases over years, seeking other opinions when needed. They may take out insurance on a judge's life against the risk that the judge dies before the case concludes.

    Leaving apart patients' preference for continuity, not to mention the vast human cost of poor “relaying” of medical information, the financial toll is surely high. We know that medical error is costly and common, scarily common. One in 10 medical encounters is said to result in harm, as the US Institute of Medicine's landmark 1999 report To Err is Human: Building a Safer Health System and many reports since have shown. We also know that poor communication is a common cause of medical error. In their book Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes (2004) Robert Wachter and Kaveh Shojania argue that “behind every error there is a second story, one with a complex mix of miscommunication, low cultural expectations and poor teamwork.”

    Why the NHS and those who use it tolerate a service where communication is so poor is hard to answer. The low expectations cited in Internal Bleeding may come into it, or maybe the business case for putting more resources into tackling error that is due to poor communication and lack of continuity has not gone far enough.

    Initiatives to tackle medical error are certainly not lacking. Over the past 10 years the number of organisations, national and international, committed to improving the quality and safety of health care has burgeoned. In most healthcare systems, and the NHS is no exception, data on errors and near misses are routinely collected; how systematically and effectively the data are used as a learning tool to reduce error is open to question. Some would argue that the proliferation of initiatives to improve safety suggests that we are some way from getting on top of the problem.

    Establishing common electronic health records in the NHS and sharing these with patients ought to help solve many of our communication problems, but they are a long time coming. Furthermore, Glyn Elwyn, professor of primary care at Cardiff University, says that Connecting for Health may be more focused on producing a data processing tool than one that promotes case coordination.

    Time will tell—but while we wait for the Holy Grail we can surely pursue some simple measures. Professor Elwyn suggests providing incentives for GPs to appoint a personal doctor to maintain continuity of care for acutely ill, dying, or complex patients, and the quality and outcomes framework (QOF) springs to mind as a mechanism to achieve this. Another approach would be to adopt the social services model where case managers are responsible for collating information on patients' access to diverse services. What is certain is that we need a more energetic debate on how to develop local solutions to tackle local communication problems.

    No one should underestimate how stressful it is to be left, as Penny Campbell was, to steer your own patient journey. Doctors can't guarantee a good outcome but they can, and should, help patients navigate their way as safely as possible through our complex and fragmented health systems.

    Patients are constantly being asked to supply “missing” bits of their medical jigsaw