Communicating with external agencies
As part of an occasional series on communication, we look at the benefits of – and the barriers to – communicating with external agencies, and what can happen when it goes wrong.
The single biggest problem in communication is the illusion that it has taken place. Attributed to the playwright George Bernard Shaw, how those words ring true. Anyone working in primary care can relate to this sentiment but why does this happen? And what impact does this have on patient care?
PRACTICE NURSES’ ROLE
Communication with outside organisations and care providers is an integral part of the practice nurse’s role. Primary care isn’t an organisation that stands alone, indeed it is a portal to accessing appropriate services and referral pathways to provide enhanced care for our patients. It is vital, therefore, that we have not only an understanding of the wider community from which our patients can benefit but also that we ensure that we know how to communicate with these services and access them. The RCGP General Practice Foundation General Practice Nurse competencies framework stipulates that practice nurses need to have an understanding of the interface with other practitioners and agencies and ‘work effectively with other disciplines to enhance patient care’.1 Moreover, the recently revised NMC Code reiterates that nurses need to ‘act in partnership’ with our patients to access health and social care.2
OUTSIDE AGENCIES
So who do we need to be able to communicate with, beyond the four walls of our surgeries? (See Box 1) Looking at a typical morning’s list it is evident that we need to communicate with a wide variety of disciplines and agencies in order to carry out our job effectively. There’s the young mother who is returning for her swab results which are not back yet so you will need to contact the laboratory; the gentleman recently diagnosed with diabetes is keen to access the DESMOND self-management education programme you’ve discussed with him; there’s the elderly lady living alone with dementia and her daughter needs to know what support is available; the teenager with a positive pregnancy test and doesn’t know which way to turn; the patient with a deteriorating post-operative wound really needs to be seen by the district nurses at the weekend. All these patients need us to act on their behalf, with their permission and collaboration, and ensure that we communicate with the appropriate agencies to enable a continuity of care.
HOW DO WE COMMUNICATE?
There are many ways in which we can communicate with external agencies but it’s knowing the correct referral or pathway. Sometimes it may be a phone call, fax or email. Another time it is speaking with the GP to instigate an ultrasound referral for a patient. It may be that the district nurse has just come to the surgery so you can speak to them about the dressings to be done at the weekend although this may then need to be followed up more officially through the ‘proper channels’. Clearly there are some referral pathways that are relatively straightforward. CCG websites can be an extremely useful resource for finding information for accessing a wide range of external services from Autism Diagnostic Services to Pulmonary Rehabilitation to Falls Assessment referrals.
Communicating through multidisciplinary team (MDT) meetings can be a hugely beneficial way of disseminating information amongst a number of professionals for specific patient groups. Holding monthly MDT meetings to discuss, for example, the frail and elderly patients in your practice with the GPs, district nurses, community psychiatric nurse and social care personnel allows a team approach to manage the care of these vulnerable and ‘at risk’ patients and to avoid hospitalisation. Equally, meeting regularly with the palliative care team, as part of the Gold Standards Framework, to review patients on the palliative care register enhances communication between the relevant agencies involved in a patient’s end of life care.
Integrated care framework and shared records
Integrated care models are emerging between primary, community and secondary care for the management of chronic disease to improve the delivery of care to patients. The management of diabetes through integrated care, in particular, is an example of improvements in the communication between services to provide a high quality level of individualised care for people with diabetes.3 Such a framework allows wider access to specialist expertise by the primary care team and support and advice from outreach teams delivered locally. Intrinsic to this pathway of care is the integrated IT system that allows Enhanced Data Sharing (EDS) of patient records between primary and secondary care. It enables rapid communication and referral and allows each discipline to view each other’s records to make the best clinical decisions for that patient. Such an improved system of communication and forging links between primary and specialist care enables more complex care to be given locally together with greater access to education for both patient and practice nurses alike. This is a real example of where technology can enhance patient care through better communication.
Gaining patient consent to data sharing in this way is paramount before this can occur and patients need to be reassured that they have complete control as to how or indeed if their information is shared. It may also be pertinent to distinguish between this type of Enhanced Data Sharing and the electronic Summary Care Records which are used by NHS England to support patient care as the issue of sharing patient information can be somewhat confusing and easily misunderstood.4
BENEFITS OF GOOD COMMUNICATION
The ultimate benefit of good communication is, naturally, to the patient – either to provide additional support, referral for further care, engage in education or simply to find out pathology results. Knowing local pathways and local information is certainly key to communication. For example, what is the local procedure for an abnormal cytology result? Whose responsibility is it to follow up that result? Having adequate resources and updated policies and procedures within the practice are essential to enable a smooth flow of communication externally. Who actually sends the fax to the Malaria Reference Laboratory about your query about malaria chemoprophylaxis? Do you confirm that it has been sent and is it then documented in the notes? Do you assume it has been received?
Having face-to-face contact with certain specialists such as the specialist nurse at the renal unit or the local school nurse often aids communication – putting a face to a name means they are therefore more likely to be remembered, and although it is clearly not possible to visit every department and service sometimes opportunities do arise through study days and departmental open days where you can get to meet professionals from other disciplines. Yes, we live in a world of efficient technology which has improved some areas of communication beyond belief but having personal contact with your district nurses, health visitors and midwives completes the picture. Even though you might have to undertake the appropriate paperwork and submit an official referral document for, let’s say, a mental health referral, a personal chat with your Community Psychiatric Nurse as well can make a huge difference to the patient concerned.
Recognised secure email systems, supported by the NHS, are replacing traditional methods of communication and as a result are proving to be a safe, rapid and cost-effect way of communicating with other agencies. For example, referrals for investigative procedures are often expedited, information between GPs and community teams can be shared more efficiently and accurately and hospices can advise primary care teams immediately when a patient is discharged to ensure a continuity of care occurs as soon as they have arrived home.
BARRIERS TO COMMUNICATION
A referral to the DESMOND programme for example may simply be a fax or electronic transfer to the appropriate agency. But sometimes the problem is remembering to do it at the end of a busy morning’s work. Or maybe you’re not quite sure how to do it and intend to ask someone and come back to it later. Then don’t. Or, as has happened, the fax number has been changed without anyone in the practice realising it, and the referrals don’t arrive at the intended destination. And if that is the case, where has that patient information ended up?
Just not knowing how to do things can be a barrier to communicating with external services but it is certainly no excuse. Ignorance or inexperience won’t stand up at a hearing. Frustratingly, trying to speak to other professionals on the telephone is not always straightforward. How many times have your tried to telephone someone such as the continence nurse or the health visitor with limited success? You ring to discover they are not available and so leave a message on their answer machine. They return your call but you are now with a patient so you are unable to take it. You try again once your patient has left and it’s the answerphone again. You then have a day off and miss their return call. And so it goes on.
WHEN COMMUNICATION GOES WRONG
As much as good communication benefits the patient, clearly poor or absent communication is inevitably going to be detrimental to a greater or lesser extent. What happens when an HbA1c reported by the laboratory confirms a diagnosis of diabetes and that is never communicated to the patient? What are the consequences when a referral to secondary care ‘goes missing’ and the patient doesn’t like to bother the doctor to find out why they haven’t heard from the hospital? And then there’s the unthinkable. We do have to remind ourselves of the most devastating of consequences in failure to communicate with multi-agency professionals when safeguarding children and adults from harm. Sadly, serious case reviews often state poor communication as a significant contributory factor when abuse goes unchecked.5,6 When confronted with the thought that poor communication can at its absolute worst result in such tragic consequences it seems trite to blame lack of time, tiredness, feeling overworked or the general mayhem of primary care.
Even in less serious offences, lost DESMOND referrals could culminate in delayed intensive education for these patients and subsequently they could miss out on the benefits of the legacy effect of good early control of their diabetes to reduce long term complications. Being unaware of local knowledge can impact significantly on how we communicate. For example, referral pathways for abnormal cervical cytology can differ from area to area. It may be that a practice nurse working at one surgery has been used to the system of direct referral from the local Cervical Screening Programme, whereas at her new surgery referral needs to be made by the practice. It is an opportunity for error.
In a report last year, NHS England raised concerns about the risks to patient safety on discharge from hospital due to poor communication and inadequate discharge summaries to primary care.7 From a practice nurse’s perspective, a lack of discharge information may be having no advice regarding individualised wound care, the duration for the continuation of anti-thrombotic agents, whether there is ongoing care from the community nursing team, or a lack of instructions for specific medical devices to name but a few – all of which can directly affect patient care. Communication between the two sectors is therefore vital to protect patients’ safety and ongoing care and such a report emphasises the consequences of poor communication.
COMMUNICATION AND DOCUMENTATION
Sometimes the way in which we communicate with external agencies and services automatically saves a record in the patient’s notes. Many practices use electronic forms for referral to the diabetic foot clinic or community services, for example. Evidence is then left in a patient’s notes that contact or referral has been made to a specific service, when that occurred and by whom. Details of other means of communication, such as phone calls, need to be added to a patient’s records contemporaneously, accurately outlining the specifics of those conversations. This also includes the documentation of failed attempts at making contact with a specific service, such as having to leave messages on the occupational therapist’s answer-machine or repeated unanswered calls to Child Health. Accurate record keeping is essential to nursing practice, but also on another practical level, it can provide a valuable ‘aide-memoire’ when you can’t remember the name of the staff nurse from the Renal Unit from whom you need to seek further advice that day or indeed whether a colleague has received a phone call from the school nurse in your absence.
SELF-REFERRAL
Communicating with other services may sometimes be a question of pointing the patient in the right direction. Many services, such as physiotherapy and some mental health services, do not require a referral from primary care but encourage self-referral from patients themselves. Practice nurses need to be aware of what is available locally and know how to advise patients so they can access such services. Indeed, the services themselves need to ensure that updated information about self-referral is communicated to primary care with many now taking to social media to provide details of their services.
TIME
Very often our communication with other agencies feels like an ‘add-on’ to our daily work. During your shift you acquire additional things that need to be done for the patients you have seen, be it seeking advice from the specialist stoma nurse, a query with Child Health about a specific child’s immunisation records, a discussion with the NaTHNaC specialist travel nurses about a traveller’s complicated itinerary. So at what point in our day do we actually get the opportunity to manage this successfully?
Does it need to be said? Time is essential to good communication. We need time to undertake the phone call, complete the online referral, speak to the health visitor, fax the podiatry form. Not just time, but uninterrupted time. Where our focus is undisturbed. Or in reality are there half-started jobs that fail to be completed as colleagues and patients alike invade any moments of contemplation? The intention was always there. It’s no wonder at times we have had the illusion that communication has taken place.
If you missed Katherine Hunt's article ‘Communicating with the practice team’ catch up here.
REFERENCES
1. RCGP General Practice Foundation. General Practice Nurse Competencies. RCGP, 2012 Available at: http://www.rcgp.org.uk/membership/practice-teams-nurses-and-managers/~/media/Files/Membership/GPF/RCGP-GPF-Nurse-Competencies.ashx
2. Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses and midwives. London, 2015 Available at: http://www.nmc-uk.org/Documents/NMC-Publications/revised-new-NMC-Code.pdf
3. Diabetes UK. Improving the delivery of adult diabetes care through integration. London, October 2014. Available at: http://www.diabetes.org.uk/Documents/About%20Us/What%20we%20say/Integrated%20diabetes%20care%20(PDF,%20648KB).pdf
4. NHS Choices. Your Records. 2013 Available at: http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/overview.aspx
5. Coventry Safeguarding Children Board. A Serious Case Review: Daniel Pelka. Overview Report. 2013 Available at: http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf).
6. South Gloucestershire Safeguarding Adults Board. Winterbourne View Hospital. A Serious Care Review. 2012. Available at: http://hosted.southglos.gov.uk/wv/report.pdf
7. NHS England. Patient Safety Alert. Stage One: Warning. Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care. 29 August 2014 Available at: http://www.england.nhs.uk/wp-content/uploads/2014/08/psa-imp-saf-of-discharge.pdf
