In my view… Laurence Dorman writes

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Introduction by Donald Li
As clinical care becomes increasingly complicated, and family doctors are more and more stretched by what we are expected to deliver to our patients, communication between clinical colleagues becomes increasingly important. When health systems are under pressure, however, good communication between colleagues in primary and secondary care can deteriorate quickly. This month I have invited, Laurence Dorman, incoming Chair of Royal College of General Practitioners (RCGP) in Northern Ireland, to describe the initiative developed by all the specialties working in the health sector there, to improve the interface between primary and secondary care by communicating better.

Laurence Dorman writes
Frequent examples throughout medical history have shown that simple, low tech interventions can have significant impact on population health. Vaccination programmes, clean water and provision of high-quality primary care are such examples. In my view, good communication between medical professionals which promotes professional courtesy and mutual respect can have a similar significant impact on patients’ lives, with a simple approach and low cost.

The delivery of high quality, safe primary care is dependent on the support of our secondary care colleagues. The essence of family medicine is carrying risk when presented with vague or unexplained physical symptoms. It is the difficult job of the family practitioner to carry that risk and establish on behalf of the patient: “Is it serious doctor?”.

The access to subspecialties provided by our colleagues in hospitals must be a supportive process. It should have good communication and the ability for family doctors to ask sometimes unusual questions, in a supportive and blame-free environment. There must be no such thing as a stupid question. Equally, family doctors have the responsibility to refer patients appropriately, in a timely manner and to the correct person or department.

Following the dissemination in 2016 of two significant reports on the health system in Northern Ireland (1) (2) the importance of primary care and caring for patients in their own communities was publicly recognised. The theme of ‘collective leadership’ featured strongly in both documents and highlighted the need for all doctors in Northern Ireland to work in a collegial and collaborative way. To succeed in transforming health care services in Northern Ireland we must work better together.

Increasing human and financial resource pressures in the health sector have created and exacerbated tensions between primary and secondary care colleagues. Hospital services which were swamped by referrals from GPs felt that the GPs had omitted to clearly convey the reason for the referral and did not contain sufficient information to allow the consultant to make an informed diagnosis. On the other hand, GPs felt work was being passed from hospital to primary care which was unfunded and poorly communicated.

Patient safety was also at risk and several cases have been documented of significant clinical events where poor communication has resulted in adverse outcomes for patients. These have included investigations done in secondary care requiring follow up or further treatment which have been passed to primary care to do, without adequate communication or agreement about who should take responsibility.

General practice recruitment in Northern Ireland had also started to suffer. In her landmark publication in 2017 “By Choice – Not By Chance”, Professor Val Wass noted that significant denigration of General Practice by hospital staff was experienced by medical students. In Section 6 of the document ‘the influence of the hidden curriculum’, Prof Wass made a number of recommendations including: ‘Work should take place to tackle undermining of general practice as a career across all medical school settings including primary care’. (3)

In January 2018 the Royal College of General Practitioners in Northern Ireland (RCGPNI) felt compelled to act and lead on this important issue. Discussion with our members revealed that doctors were severely overstretched in their roles and a deep sense of “us and them” had developed between primary and secondary care clinicians. One member’s testimony was particularly poignant:
“When we were together in medical school, we were all such close friends. It is hard to comprehend how we have ended up so distant and at logger heads with each other.”
In March 2019 RCGPNI led a social media campaign to highlight this important issue and to promote an environment of professional courtesy and mutual respect. We initiated a positive social media campaign where GPs were encouraged to use the greeting “Dear Colleague” when referring to their secondary care colleagues. At the same time, secondary care colleagues were encouraged to use the same greeting when writing discharge or clinic letters to their GP colleagues. The event was heavily promoted on Twitter using the hashtag: #DearColleague.

The emotion behind the initiative struck a chord and it was followed up by a successful meeting with representatives from other clinical Royal Colleges. Following this, we developed together a set of 10 principles to guide doctors on ways to improve effective communication and behaviours to maintain good professional relationships. See the 10 principles at the links. (4)

As a group, comprising members of all the clinical specialty colleges, we quickly discovered the importance of words and the nuance of language. We were keen for our document to help to model professional behaviours so the first three words in Point 1 were highlighted: “Leading by example”. The 10 principles reflected the various issues which all the Royal Colleges felt had obstructed good communication. The patient voice was also represented by encouraging clinicians to write to patients in clear and appropriate language as recommended by the Academy of Medical Royal Colleges (5)

The document has developed a dynamic within clinical practice and medical education. Work has begun to ensure the principles are embedded in the medical undergraduate curriculum, with emphasis on how to model behaviours and work seamlessly between specialities. The principles will be promoted to doctors entering specialty training programmes, and hospital trusts have agreed to incorporate it as part of their induction training and staff handbooks. The individual clinical colleges are also bringing individual pieces of work together to highlight how good communication leads to good collaboration.

Good communication is much more that remembering to say “Please” and “Thank you” – although that is a good start. In my view, the promotion of professional courtesy and mutual respect, where we acknowledge each other’s roles, can help ensure we all act as one healthcare system to improve the care of our patients.

References:
1) https://www.health-ni.gov.uk/sites/default/files/publications/health/expert-panel-full-report.pdf
2) https://www.health-ni.gov.uk/sites/default/files/publications/health/health-and-wellbeing-2026-delivering-together.pdf
3) https://www.hee.nhs.uk/sites/default/files/documents/By%20choice%20-%20not%20by%20chance.pdf
4) https://www.rcgp.org.uk/-/media/Files/RCGP-faculties-and-devolved-nations/Northern-Ireland/2019/RCGP-principle-leaflet-2019.ashx?la=en
5) https://renal.org/wp-content/uploads/2018/02/draft-proposal.pdf

About Laurence Dorman
Laurence Dorman is a family doctor working in a rural town in Northern Ireland. He is a fourth-generation family doctor. He has been the RCGP in Northern Ireland Strategic Advocate for Interface and Communication since 2017 and assumes the role of Chair of RCGPNI in November 2019.