Monday, 25 February 2013

The Pretence of Better Communication

This blog was first published at doc2doc It has been modified, extended and re-posted here.

Discharge Summaries in NHS
10 years ago in the NHS most consultants used to do discharge summary letters for their in-patients. Quite rightly so. The discharge summary was and is the only communication that the hospital provides to primary care on what happened to the patient in the hospital. It is one of the most important pieces communication that the specialist sends to the generalist. It was the knowledge of the expert given as an opinion. It was also an opportunity for the consultant to review and reflect on the care provided, identify errors and recognise the capability/limitations of the team members.

5 years ago the consultants mostly devolved this responsibility to some experienced staff working with them such as Staff Grades or Registrars. The discharge letter became a task that had to be done. Information was passed to the general practitioners.

Now, the discharge letters are electronic and are primarily if not exclusively done by FY1s or FY2s who are the least experienced doctors in the system. Discharge letters are a part of the contractual requirement to be sent within a set time. There is enormous data within those discharge letters which is sent to the GP more or less contemporaneously. The junior doctors do a very good job; of transmitting data; they cannot with their level or training, expertise and experience do anything more.

Anyone who knows a little about this things will recognise that to derive any meaning or learning from what we do on a day to day basis, data has to be processed and assembled to generate information; information has to be analysed and contextualised to create knowledge. In the case of the NHS discharge summaries, knowledge transmission has now deteriorated into data transmission. Transparency and detail which are important have taken the place of trust and succinct senior opinion which are equally important.

The most crucial and often the only piece of communication from hospitals to general practices is now generated by a combination of off the shelf software programmes filled in by the junior most medical staff and usually has no oversight from anyone senior. Of course there are reasons for this, the letters can be generated quicker, can reach general practitioners on time and the current economic climate a consultant who is an expensive human resource is better used doing actual clinical work. Fully understandable. But let us not make the mistake of assuming that this is superior communication.

A friend who works on analysing and reporting risks in financial industry wrote in to say 'in my area of work if I do not provide the final oversight on what gets published on the credit opinions..which can sway bond error means I can be banned from working in financial services...if related to sovereigns...maybe jailed as well'. Now that's how seriously communication should be taken.

The Abuse of Communication Skills

Now that this blog has a growing readership; friends and acquaintances are writing in with examples from their own places of work. There seems an increasing cultural tendency where people think its okay to abuse communication skills. Righting a wrong not by action but by words. Not fair but read on.....................

Car Parking Vs Patients

Clinician running late, found a parking place and noticed that the parking permit was missing. Dilemma. Go to work and ring security to inform - risk of clamping and £60 fine. Go to security first and late to work - patients waiting.

Decision. Go to security first. Cannot afford £60 fine.

Explanation: 'Oh we can apologise to patients, show them empathy, sympathy, tell them our story, sit by their side rather than opposite them, perhaps even hold their hand and build a better relationship. They will forget the waiting. But security will clamp and will fine £60; my work place will not be supportive'

'We can handle complaints'

Bed manager rings on-call doctor: 'Try and send patients home from A&E, there are no beds in the hospital and we don't want patients to breach in A & E'

On-call doc: 'Well, apart from clinical reasons, there is also patient expectation. We could have serious complaints'

Bed manager: 'Oh don't worry about that. Complaints come only later. We can handle that. We are really good at handling complaints. We can provide them a detailed explanation and an apology if necessary'

Those are classic examples of abuse of a good skill. I have a problem with people using great tools and doing wrong things with it.

Let us get real. Let us not delude ourselves in the NHS by harping on about the primacy of communication.

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