How to improve communication from GPs to hospital specialists at the point of referrals? A systematic review via critical interpretive synthesis of qualitative data alongside quantitative data

Problem

The professional relationship between GPs and hospital consultants is important in a healthcare system where the GPs are the gate-keepers for hospital services. However, There are well-documented problems in the UK with mutual understanding and communication between GPs and hospital specialists. Effective communication across the primary-secondary care interface may be lacking in practice, with each party focusing on its own tasks and resources rather than on the system as a whole and a lack of clarity of division of responsibilities. Most research exploring the communication processes across the primary-secondary care interface has concentrated on the discharge processes from the hospital to the community. There is less research on the communication processes from the GPs to the hospital, i.e., GP referrals. Yet some studies have found that these issues are a major source of operational failures during GPs' day-to-day work, with referrals returned to GPs without any clinical action being taken, resulting in further work for GPs.

Approach

In order to address the gap in existing literature, this systematic review evaluates the impact of more direct means of communication between primary care and secondary care during referrals (e.g. email messaging or teleconferencing), as opposed to conventional means of communication (mainly via letters), on the relationship between GPs and hospital specialists. MEDLINE, Embase, CINAHL and the Cochrane Library were searched from inception until March, 2022. Additional grey literature searching was undertaken on the NIHR clinical trials gateway, and NICE Local Practice Case Studies website. There are no restrictions on the types of study design or publication date. Quantitative evidence was incorporated alongside a review of qualitative data. A checklist based on the Quality Assessment for Diverse Studies 195 (QuADS) tool was used to assess quality.

Findings

Twenty-nine primary studies published from 1969 to 2021 were included, covering a wide range of specialties. The interventions in these studies included specialist outreach clinics where case discussion with GPs were facilitated (14/29), joint teleconsultations between hospital specialists and GPs and patients (6/29), and direct email messaging (3/29), among others. These interventions were often multi-faceted involving specialist collaboration with primary care, education or other services and appeared to be associated with improved satisfaction for doctors and patients, streamlined patient pathways, reduced outpatient referral rates and less use of inpatient services. However, the benefits to patients and clinicians are certain, and the cost-effectiveness of these interventions requires further assessment.

Consequences

This is the first systematic review on interventions to improve communication between GPs and hospital specialists during referrals in the UK. This review supports the hypothesis that interventions that allowing enhanced communication and relationship-building between GPs and hospital specialists at the referral stage may have some benefits. However, there is not consensus about what approaches to improving communication are most acceptable.