Specialists and GPs agree: outpatient processes are broken

By Siobhan Calafiore

22 Nov 2023

Co-designed discharge policies, improved electronic communication tools and a rapid hospital review pathway following discharge could help improve current hospital outpatient discharge processes to general practice, researchers suggest.

Their study involving interviews with 15 doctors (nine hospital doctors representing seven specialties, six GPs) revealed that about 20-60% of hospital outpatients were receiving unnecessary appointments and could be managed in primary care.

The researchers, which included former RACGP vice president and former Queensland chair Dr Edwin Kruys, said GPs were prepared to provide continuation of care to these patients but required timely clinical management plans to do so.

One GP interviewed said: “I see a lot of outpatient appointments that seem unnecessary, because they’re monitoring things or they’re doing things that we could do as GP if we just received better communication from the hospital.”

Interviewees mentioned multiple system issues hindering discharge from hospital outpatient clinics, including limited electronic communication tools, workforce and workload challenges, and a lack of hospital benchmark data on discharge rates.

Hospital doctors indicated they kept patients under their care out of a concern about lack of follow‐up and an inability to escalate timely hospital care following discharge. Other factors mentioned were a patient preference to remain under hospital care and ease of scheduling follow‐up appointments once in the clinic.

There was also lack of trust in the capacity or skills of other clinicians in follow-up, according to the findings published in BMC Health Services Research [link here].

One specialist said: “There is always that element of, no one does it better than yourself – type thing, which is a bit of a weird thing but I know what I’m looking for so I should probably then follow it up.”

When patients were discharged, GPs complained that they did not always receive clinical handover correspondence and test results from the outpatient clinics, leaving them “trying to find out what’s happened” for most of the consultation.

This delay was often blamed on fluctuating capacity to write and authorise letters.

Hospital doctors suggested a standard template could speed up the process.

“You could have a drop-down list of things that you can add on and then you can potentially free text some of the more individualised options for that patient.”

The inability of hospital clinicians and GPs to efficiently communicate with each other via secure, electronic means due to a lack of interoperable communication systems between hospitals and general practice was also frequently brought up.

Other deficiencies in the system included there being no consensus about when to discharge patients and when to share care with GPs or whether there were patient groups who should continue to be booked for outpatient follow-up appointments.

Several system improvements and models of care were also suggested, such as agreed discharge processes co‐designed between hospitals and general practice.

Many interviewees supported a hospital re‐entry pathway to escalate care back to outpatient hospital resources post discharge when required, which could act as a safety net and an alternative to the standard 12‐month hospital outpatient review.

A limitation of the study was the involvement of just one hospital in Queensland.

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