Hopefully, one excellent and overdue outcome of giving commissioning powers to GPs will be that we conquer the problem of inadequate or no hospital discharge summaries about our patients and their medication.
However, getting the discharge process and summaries right is not a simple matter.
We all know patients whose medications were changed, stopped or replaced without explanation to their GP, the practice, the patient or the carer. Not surprisingly, medication errors occur and are a common reason for legal claims.
There are good reasons why hospital admission, with an acute episode of existing illness or a new diagnosis, may result in the drugs the patient was taking on admission being stopped and new drugs given. But when GPs are asked to continue prescribing a treatment initiated in hospital, we should have enough information to prescribe the drug safely.
If the discharge slip does not contain enough information about the changes that have occurred, the result can be treatment failures, continuation of inappropriate medication and discontinuation of required medication.
Good prescribing is one of the criteria of the GMC's Good Medical Practice guidance.
GPs are responsible if a patient suffers drug-related harm by inadvertently following a consultant's instructions.
We are also responsible if we do not spot hospital-initiated medications - for example, if a practice receptionist prints all the items on the discharge medication slip and the GP simply signs the prescription without noticing the changes.
From April 2013, GP consortia will commission the majority of NHS services for patients, and meaningful control of limited resources will mean looking at three Es - efficiency, effectiveness and economy - to ensure outcomes are optimised for the level of funding used.
With these provisos in mind, our practice at the Chadderton South Health Centre in Oldham, together with another Oldham practice, last year undertook an audit of medications prescribed on discharge to ensure consistency and effectiveness and to reduce medication errors. As well as harming patients, the last can result in costly re-admissions. See the box below for how we carried out the audit and the results.
Results show a problem
Our audit was presented to the local medicine management committee in January 2011 as part of its Quality, Innovation, Productivity and Prevention (QIPP) agenda to prevent ill health and re-admission.
The results indicated a problem, but we could not say how many resulted in re-admission. The difficulty in interpreting the results comes from the reasons why what should have happened did not.
For example, it is justifiable not to give a seven-day supply if the patient already has a large amount of the medication, but how is the GP supposed to know that if it is not documented? If the consultant's name is missing, who should the GP contact if there is a concern about the medication?
A delay in getting summaries means the practice does not know what happened when the patient was in the hospital. It is not appropriate to rely on the patient/carer to provide details about the drugs they have been asked to take and why.
Our audit's limitations included small sample size. Only one hospital site's discharge summaries were studied and surgical cases were not included. Nevertheless the medicine management committee acknowledged there are problems in communicating discharge medications information.
We intend to continue the audit, involve more practices and extend it to other practices to get a wider picture. The solution is collaborative working by health professionals to identify how to improve the discharge process. This type of research will help GP consortia when they take on real budgets and face real, fiscal consequences for overspends.
Once GP commissioning is fully in place, consortia will have more control over acting in the best interests of patients.
Including pharmacists in practice teams would be a good safeguard for patients and, may be, there is a need for electronic discharge prescriptions.
|DISCHARGE MEDICATIONS AUDIT|
- Dr Sharma is a Greater Manchester GP and Lyndsey Black is a fourth year medical student at Manchester University.