Improving communication to GPs for complex discharge scenarios: a scoping review and qualitative study of GP perspectives

Problem

Poor communication at hospital discharge continues to threaten patient safety and quality of care. Communication to GPs relies on discharge summaries that are usually written by the most junior doctors, who are inexperienced and can lack insight into community care. To improve quality, national improvement efforts have focused on guidance and standardisation through discharge summary templates. These have produced significant safety benefits for many patients, particularly those with simpler, more ‘linear’ care. However, this increasing standardisation has been described as less effective for patients with more complex care. Previous work has found that optimal communication of these complex discharge scenarios may not ‘fit’ a standard template, potentially constraining key narrative and explanatory aspects.

This complexity may also increase the risk of harm and suboptimal care, with more dynamic templates and additional communication measures offering improvement opportunities. However, a consensus of what determines complexity at discharge is lacking. Greater understanding of the characteristics of complex discharge scenarios and their key challenges is required to delineate a target cohort and develop improvements. Previous work has highlighted a key need to understand the perspective of GPs to achieve this.

Approach

A scoping review is being conducted to clarify and map the existing literature regarding ‘what factors determine complexity at discharge?’. This is informing a qualitative study consisting of semi-structured interviews of up to 15 GPs, which will explore their recipient perspective of discharge complexity. Detailed clinical vignettes will serve to highlight factors relating to the patient, other stakeholders and the surrounding system. The issues that complexity can create will also be explored, alongside improvement opportunities beyond the status quo of a discharge summary. To gain a breadth of perspectives, GPs will be purposively sampled based on time since qualification, and the socioeconomic status of their practice populations.

Findings

Early review work has found that the term ‘complex’ is used heterogeneously, demonstrating a lack of consensus. Heqvist et al have recently described the complex features of the systems that surround patients at discharge, demonstrating the importance of the interactions between stakeholders and a system’s components. Their demonstration of interdependencies between elements and resultant ‘emergent’ properties shows how a complex discharge scenario can resemble a ‘complex adaptive system’ (CAS). Importantly, CAS’s benefit less from standardisation as compared to less complex systems. These concepts from complexity science are therefore informing the topic guide for the GP interviews, to further explore higher complexity cases.

Consequences

This study aims to develop a prototype model of complexity at hospital discharge. This will serve to highlight higher complexity discharge scenarios with consideration of the recipient GP perspective. In turn, this model will aim to demarcate discharge scenarios that may benefit from additional communication measures, to improve safety and quality of care.