GPs are facing increasing practice workloads with growing patient lists, reduced resources and staff shortages – this is not exactly news. NHS England as part of its GP Forward View has been looking at ways to ease these burdens through various means, including correspondence management strategies in which non-clinical or administrative staff are employed to process and action practice mail, freeing-up GP time to spend on more complex patient issues.
One practice in Brighton and Hove piloting a scheme to improve processing of administrative work found that a “significant number” of letters required no clinical input. A GP at the practice told Pulse Online that he spends approximately 40 minutes each day processing mail outs, of which 80 per cent could be dealt with administratively.
Workflow optimisation or correspondence management has been shown to ease GP workloads but concerns have been raised that the process may put patient safety at risk.
"LOW RISK" CORRESPONDENCE
A large proportion of mail received by practices can be identified as “low risk”, with GPs happy for staff to send it straight to file with no action required. An example of one workflow optimisation protocol involves management of correspondence that requires no clinical input, such as discharge letters from accident and emergency departments where the patient has attended with a minor injury, such as a sprain or strain, or for an acute medical condition such as a sore throat. Usually the patient receives sufficient treatment and/or advice requiring no further action for the GP, therefore this can be sent straight to the patient’s notes, possibly being coded, but with no further action.
Another form of communication that may be considered low risk is a letter from secondary care informing a GP that their patient did not attend an appointment. This can be frustrating – considering buckling hospital waiting lists – but there are many reasons why a patient might fail to attend a hospital appointment. From a risk perspective, it is important to consider the patient as an individual and, in particular, whether they have capacity and fully understand the reason for the referral along with the consequences of not attending, or if they are vulnerable in some way.
A recent call to one of our medical advisers from a practice manager concerning a patient diagnosed with dementia highlights this issue well. A GP had referred the lady for a secondary care opinion but, after the hospital had sent her three offers of appointments without response, she was discharged back to the GP. A letter detailing the patient’s failure to attend was sent to the GP and this was filed straight into the patient’s notes, without being highlighted to the doctor. The patient’s condition deteriorated and it was some months later when a related acute problem arose that the GP first became aware that the patient had not been reviewed at hospital. In fact, it was likely that the patient had disposed of the appointment letters without her carers or family being aware.
If this 'DNA' letter had been actioned or recorded in a way that highlighted the risk to a GP then it is likely that the patient would have been followed-up, which could have prevented a worsening of her condition.
PROTECTING VULNERABLE PATIENTS
Workflow optimisation has been identified as a way to ensure GPs have time to focus on work that only they can do. However, to ensure that new ways of working are safe, it is imperative that the practice agrees and provides clear guidelines to staff on which patients would be likely to fall into the ‘vulnerable’ or urgent category. Indeed, many practices have created ways of flagging these patients clearly so that non-clinical staff can then direct any mail concerning them to the referring GP so that a clinical view can be taken on whether the patient requires follow-up. Vulnerable patients might include:
- older patients who are physically or mentally frail
- patients with learning disabilities
- patients with certain mental health conditions such as dementia
- homeless patients.
Once safe systems are agreed and staff trained, it is important to consider what safety-netting measures the practice could implement to ensure that mail is being actioned correctly. Should there be a GP lead and a procedure to ensure practices are regularly auditing this activity? One solution that some practices have adopted is to nominate a "safeguarding officer" to whom this sort of mail may be directed for follow-up.
SECONDARY CARE CORRESPONDENCE
It is also important to consider what responsibility hospitals have in contacting patients who miss an appointment, rather than discharging them back to the GP. NHS England has stated within the GP Forward View: "a provider’s local access policy must not involve blanket administrative policies under which all DNAs are automatically discharged; rather, any decisions to discharge are to be made by providers on the basis of clinical advice about the individual".
If secondary care doctors are provided with enough clinical information about a patient’s medical condition, vulnerable status or relevant social situation as part of the referral process, they should take into account whether the patient’s vulnerability is likely to be a cause for failing to attend and try to contact the patient by another means instead of simply removing them from their list.
In general, good documentation is key in supporting clinicians involved should any issues arise as a result of a patient DNA. The GMC provides advice on recording your work clearly, accurately and legibly within Good Medical Practice (paragraphs 19-21) and states that clinical records should include "the decisions made and actions agreed, and who is making the decisions and agreeing the actions".
- Identify "low-risk" correspondence that may have further implications if not reviewed clinically.
- Ceate a process that safety-nets your workflow optimising procedure.
- Ensure non-clinical staff are trained in new processes and are aware of the associated risks, and know who to approach for advice if they are concerned.
- Implement quality assurance of systems to ensure patient safety is not compromised and that staff continue to be competent in delegated tasks.
- Ensure patients are fully informed about the reasons for referral and consequences should they not attend. This discussion should be documented within the patient’s record.
- Ensure referrals contain all relevant information about a patient’s status or condition that could affect their care.
- For hospital doctors, ensure you note any information contained within a referral that may impact on the patient’s ability to attend appointments and/or process any communications with them about appointments.
- Good documentation will support the clinician should any issues arise as a consequence of a patient failing to attend for further care.
Kay Louise Grant is a risk adviser at MDDUS