Thursday, 17 March 2016

NHS England test standards INCREASE risk

Yesterday, NHS England published a document setting out standards for the communication of patient diagnostic tests on discharge from hospital which dismayed GPs, who interpreted it as suggesting that GPs could be held responsible for acting on the results of tests ordered by hospital clinicians. +Pulse Today report that the most controversial element, Standard 5, has since been revised. Here is my response:

I am most relieved to see this clarification of Standard 5. Maureen Baker, NHS England and others are to be congratulated for their work to achieve such a rapid revision.

I remain concerned about elements of this document, however.

The second guiding principle ("Every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test.") sounds like a sensible safety net. However, how is the GP to know whether or not the result of a test they did not order has been acted on by the requestor? Equally, how can the requestor of any test know that the GP is competent to act on the results of a test that they might not be familiar with?

Similarly, Standard 7 ("Appropriate systems and safety net arrangements should be in place in primary and secondary care to ensure any follow-up diagnostic tests required after discharge are performed and the results are appropriately fed-back to patients.") opens up potentially unsafe ambiguity about the responsibility of post-discharge tests, especially if discharge summaries are delayed. I am sure every GP has received a discharge summary advising blood tests to be carried out BEFORE the discharge summary actually reaches the GP!

GPs should not be the default safety net for everything. Requestors of tests should retain responsibility for arranging them and actioning the results and should ensure that they maintain reasonable safety nets.

GPs are not community house officers. If a hospital doctor has made the decision that a test, prescription or referral is required, they should arrange that. If, on the other hand, they believe that the opinion of a GP (who is well placed to know what can be arranged in the community) would be helpful, they should advise the patient to consult their GP on a routine basis after the discharge summary or clinic letter has been received by the GP.

I fear this guidance actually INCREASES the risk that post-discharge tests will not be arranged or acted upon by introducing ambiguity in responsibility. BMA guidance in this area is much clearer and should stand.

1 comment:

Colin said...

This is a classic case of poor system design in a command and control system that is likely to make things worse rather than better.

First of all there is the issue of top down micromanagement. This is not an effective way to manage organisations, nor create robust systems. The role of organisations like NHSE should be to guide and support improvement within the NHS rather than come out with "standards" that are likely to have unintended consequences such as these are.

These "standards" break the principles of good system design. They introduce unneeded shared responsibility (an area of great clinical
risk), unnecessary hand offs in the work stream, and give a false sense of security.