Dr Michael Devlin examines who is responsible for patient care when treatment is started in hospital
Both hospitals and GP practices have been under extra pressures during the Covid-19 pandemic and its aftermath. At the same time, there has been progress in developing the Enhanced Community Care Programme and an increasing focus on integrated services. Despite the gradual moves towards greater integration in the provision of clinical care, there remains one area which is important to recognise as inherently risky: Shared care between hospital specialists and GPs.
It is important that shared care is properly and clearly managed and essential that systems are put in place to maintain continuity of care when a patient returns home from hospital. In the experience of the Medical Defence Union (MDU), particular risks may arise if communication fails or if it is unclear who will be responsible for ongoing prescribing.
Decisions about who will take responsibility for the patient’s continuing care need to be made at the outset. The decision should be based on the patient’s best interests and not for reasons such as the cost of medication, monitoring issues or convenience. Patients should understand the roles of the different healthcare professionals involved in their care and agree to the shared care arrangement.
Doctors sometimes seek advice about prescribing responsibilities such as when GPs are asked to continue prescribing medication initiated in secondary care. Prescribing off-label or unlicensed drugs and prescribing a drug with which the doctor is unfamiliar are also common topics.
Medication errors are also a recurrent theme in adverse incidents reported to the MDU’s medico-legal advice line. In an analysis of claims settled on behalf of MDU members problems included:
Failure to monitor long-term medication;
Prescribing the wrong drug or the wrong dose;
Prescribing to patients with a known allergy to the drug;
The Medical Council, in its Guide to Professional Conduct and Ethics for Registered Medical Professionals (the ‘Guide’), reminds doctors prescribing any medication they should, as far as possible, ensure that drugs prescribed are safe, evidence-based and in the patient’s best interests. Although not specifically addressing shared prescribing arrangements, the Guide tells doctors they “should seek independent, evidence-based sources of information on the benefits and risks associated with medicines before prescribing”. The onus is on the doctor to make such enquiries.
In practical terms, if a specialist recommends a treatment, particularly if this is a new, or rarely prescribed medicine, they will be responsible for specifying the dose and means of administration. If a GP or community prescriber is asked to continue the patient’s care, the specialist will need to ensure the patient and the GP has sufficient information to allow safe management of the patient’s condition. Put another way, this collaboration between doctors in primary and secondary care is one of the fundamental tenets of professionalism: Partnership, which relies on colleagues working together with patients towards shared aims.
Doctors being asked to take over or share patient care started by colleagues are advised to ensure that:
Patients’ long-term medication is reviewed and monitored appropriately and updated by an appropriately experienced member of staff when a patient is discharged from hospital.
You are able to recognise adverse side-effects of the medication and know what to do if they occur.
You seek further information from the specialist if follow-up, monitoring and/or prescribing arrangements are unclear.
There is a robust system for dealing with messages from patients and for giving and documenting telephone advice.
You have proper communication links with other services the patient requires support from after discharge from hospital and that a record is made of the support others are providing.
You review a diagnosis if symptoms fail to improve as expected and do not place over-reliance on negative results in the light of continuing symptoms or signs.
Medical records are organised in such a way that information about admission, discharge, outpatient or other (for example, out-of-hours) care, is easily accessible and summarised.
You keep yourself informed about other medicines that are prescribed to the patient for co-existing conditions and that the specialist is made aware of any changes.
Tasks are only delegated if it is appropriate to do so and to colleagues who are appropriately qualified and experienced.
Secondary care doctors have responsibilities to ensure colleagues are informed about patients’ needs when discharged from hospital – particularly when those needs are complex. Medication requirements should be clearly stated and discussed with the patient (and if necessary with the GP practice) and responsibilities for follow-up and monitoring clearly communicated.
Communication is the key to a successful shared care arrangement where all parties, including the patient, understand the roles of the healthcare professionals involved in their care. This includes clear documentation so that others who may become involved in the patient’s care at a later stage also have a full understanding of the differing responsibilities.
If you have concerns about continuing a patient’s treatment recommended by a colleague, get in touch with the MDU or your own medical defence organisation.
MDU membership is designed for State-indemnified doctors and gives access to expert guidance with medico-legal dilemmas. The MDU can support members with patient complaints, Medical Council investigations, inquests, and criminal matters. To find out more see www.themdu.com/ireland.
Dr Michael Devlin, Head of Professional Standards and Liaison, Medical Defence Union
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