Best practice: Ensuring safe handovers between primary and secondary care

Handover of patient care is a common area of risk, which is magnified when transferring between primary and secondary care services. Several factors contribute to this, including differing ways of working, IT systems, patient expectations and current unprecedented demands on healthcare services.  

A significant risk is failure to communicate appropriate information, which can lead to patients receiving unsafe or delayed care, in addition to placing increased demands on clinicians’ time and contributing to patient frustrations. In MDDUS’ experience, inadequate handover is a common theme in complaints, claims, inquests and regulatory investigations. 

A vital part in mitigating the risks is ensuring effective communication, which incorporates a mutual respect and understanding between clinicians as to the expertise, contributions and demands of each. All doctors have professional obligations to work collaboratively with colleagues and ensure they contribute to the safe handover of patients. The GMC’s more detailed guidance on delegation and referral emphasises the importance of clear communication and encouraging questions from colleagues.  

A doctor who delegates a task must check that their colleague understands what they are being asked to take responsibility for.  

It may be helpful also to review relevant guidance from the local commissioning body and/or your Royal College.  

Effective written communication

When sharing information between primary and secondary care, it is important to keep in mind that the purpose is to ensure continuity of safe and appropriate care.

Good communication should:

• Be provided in a timely manner. Systems should be in place to ensure written communication is sent in an appropriate timeframe. Delays increase the risk of a patient receiving unsafe care (such as continuing a medication that has been stopped whilst an inpatient), as well as placing unnecessary demands on the system (for example, patients contacting services who do not have the information to address or act on their concerns). 
• Be clear, relevant and accurate. For example, ensure your referral letters contain sufficient clinical information to determine the urgency of the referral, and that they are specific in the expectations of the clinician and patient. MDDUS has seen examples where a lack of information has contributed to inappropriate downgrading of urgent referrals. Use clear language and avoid abbreviations. A recent MDDUS case involved hospital correspondence which contained an abbreviation specific to that organisation and led to a miscommunication about the urgency of a follow-up review.
• Highlight any changes to the patient’s care and actions required, ensuring this information is not hidden in the description of events. This is particularly important where there have been alterations to a patient's medications or further action is required, such as a review appointment. The rationale behind these should be included.
• Set out the line of responsibility for outstanding actions, such as chasing results of investigations or follow-up appointments. It is usually most appropriate for the requesting clinician to interpret the results and do not delegate this to another service without specific agreement. Be clear on how outstanding information will be communicated to patients.

Involving patients

• Moving between services.  A key factor in reducing risk is ensuring patients are fully informed when moving between services. Be clear about the plan, timescales and who to contact should they have queries or further concerns. For example, when you refer a patient, they should understand the reason, urgency, expected timeframe and who to contact if they do not hear about an appointment, or if their symptoms change. 

• On discharge. Make your patient aware of any changes to their care, any outstanding actions, follow-up plans and who is taking responsibility for these. You must explain how the patient will receive outstanding results, any actions they need to take and who to contact if they have concerns. Keeping patients fully informed is an effective means of reducing risk, giving them the knowledge and means to recognise and raise issues regarding their care.

• Capacity. Where a patient lacks capacity, it is important that you involve those who care for them. For all patients who may be more vulnerable, consider whether additional action is required, for example ensuring they attend follow-up appointments.

Raising concerns

All clinicians are accountable for the information they provide. If you are unsure what you are being asked to do, or if you are not given sufficient time (for example, when completing a discharge summary on an unfamiliar patient), you must seek assistance from senior colleagues to ensure patient care is not compromised.

Where you have concerns that the handover process may compromise patient safety, you should raise these in line with GMC guidance and organisational policy.

The unprecedented demands on clinicians’ time present challenges in ensuring the safe transfer of patient care. Clear communication between services, and between clinician and patient, is essential for good and safe clinical care.

ACTION POINTS

• Take time when communicating with colleagues to ensure the information you provide is accurate and relevant.
• Make sure the most important points are clearly set out, including any changes or actions required.
• Keep patients fully informed and check their understanding.
• Raise concerns if you feel communications between services are contributing to risks in patient safety.

Dr Annabelle MacGregor, medical adviser, MDDUS

Read more on clinical handovers, delegation and referral.