Joe Rosenthal and Surinder Singh, highlight the need for two way communication between general practitioners and hospital doctors

Good communication helps everybody. Although all medical schools now provide training in communication with patients, less formal advice is given on the matter of communication between hospital and community. Over 90% of the patients who are seen, whether in casualty, outpatient clinics, or on the wards, are registered with a general practitioner, and a coordinated approach between primary and secondary care is an essential element of the NHS. Yet it is an area where problems often occur. Coordination depends on communication--whether by letter, telephone, fax, or electronic means. As junior doctors you provide a vital channel of communication for general practitioners when their patients have problems that require specialist advice or intervention, but the reverse is also true. You may need help from general practitioners, who hold a wealth of information about their patients and have access to a wide range of resources in the community.

What follows in this article is an outline of some of the areas where communication between primary and secondary care takes place and some common sense guidance on how to make that communication most effective. Communication is (at least) a two way process. We shall look first at communication coming from general practitioner to hospital and then from hospital to general practitioner.

Contacts from general practitioner to junior doctor

As a junior doctor carrying a bleep you may be the easiest person in your team for a busy general practitioner to contact by telephone. The sort of matters that may arise are listed in box 1. Often the general practitioner is dependent on switchboard operators to identify the relevant person for their query. They don't always get this right. If a call from a general practitioner comes through to you although you are not the right person to deal with it then try to help clarify to whom the call should be directed. If it is another member of your team then take a message to pass on as soon as possible.

Box 1 - Matters about which general practitioners may telephone junior doctors Urgent referrals to casualty Outpatient referrals Non-urgent admissions Request for patient discharge information General advice (clinical or administrative)

Dealing with telephone referrals from general practitioners

If you are on call or agree to see a patient urgently in a clinic or on the ward you can save a lot of time by getting general practitioners--when they call--to provide information about the patient and the problem. It goes without saying that you should always have pen and paper to hand when you are taking a phone call from a general practitioner. Listen first to what the general practitioner has to tell you and ask questions second. The first thing you need to establish with the general practitioner is just how urgent this problem is--does the patient need to be seen straight away in casualty or could he or she wait for an outpatient appointment (see box 2)?

Box 2 - How urgent? 999? See today? On ward tomorrow? Next available outpatients? Routine outpatients? Advice only?

Usually patients will arrive with a letter from their general practitioner, but it helps to have a clear idea of the situation before they arrive to see you. By the end of a telephone referral from a general practitioner you should have noted at least the following essential information: the patient's name, age, and clinical problem, a list of the drugs they are taking, their hospital number, and the general practitioner's name and telephone number (you may have to phone back for more details). Remember, all general practitioners have been junior hospital doctors for at least three years, some for much longer. They know what it is like to be at your end of the phone.

If you agree over the telephone to see a patient then further communication is needed within the hospital so that all relevant staff and departments are aware of the situation (see box 3).

Box 3 - People to pass information to after accepting a telephone referral Relevant members of your team On call team if it's not your own The ward Casualty reception Secretary Appointments Outpatients' department

Contact from junior doctor to general practitioner

As a house officer or senior house officer you may be contacting general practitioners either to provide or to seek information. The most obvious example is when you discharge patients back to their general practitioner after inpatient or outpatient care.

Discharge information

Good communication is also critical in discharging patients successfully. This is especially so with patients who need monitoring, are elderly, have just had an operation, or have complex medication or social needs. Information should flow as soon as discharge takes place and, in some cases, beforehand. Many hospitals now have discharge pro formas that are designed for handwritten completion by the junior doctor at the time of discharge.^{1 2} They can be posted or faxed to the patient's general practitioner.
It is also useful if the patient holds a copy, but do not rely on patients delivering the general practitioner's copy themselves. These discharge pro formas are extremely useful but only if they reach their intended destination promptly and are clear and legible. If you do not have a pro forma then a handwritten note is fine. The amount of detail needed depends very much on each case, but box 4 lists the minimum information required in an early discharge letter.

Box 4 - Information needed in early discharge letter Patient details Dates of admission and discharge Dates of surgery where relevant Name of consultant Name of ward Diagnosis and treatment given in hospital Medication provided on discharge (and how long to continue) Next outpatient appointment if needed Community services already arranged (for example, district nurse, home carer) Community services that general practitioner needs to arrange What patient has been told about the diagnosis Name and bleep number of junior doctor who knows the case best

If the patient is still very unwell, the case is complex, or there are concerns regarding circumstances at home it may be useful to telephone the surgery (see next section) to discuss the situation. Box 5 shows some situations where you are recommended to telephone the general practitioner. In the case of death it is not only courteous to do this, but also the general practitioner may well need to help the family over their bereavement and will need to be aware of the course of events leading to death.

Box 5 - Case scenarios in which to phone the general practitioner Self discharge Unstable condition Complex medication needs Special monitoring needs Poor home circumstances or complex Early visit needed Any death

Clinic letters

If you are writing to general practitioners after seeing a patient in clinic, rather than as an inpatient, a different kind of communication is needed. Remember that general practitioners receive a huge amount of post every day, so your letter should be clear and concise. As well as the patient's name and address, it is helpful to list main diagnoses and medication at the top of the letter. Include positive and significant negative findings in history, examination, and investigation. Any changes to medication are critically important. If these are not made clear patients may easily be given an out of date prescription when they next attend the practice. You should also describe planned investigations or treatments, and clarify any follow up or monitoring that the general practitioner will need to ensure. Again, it is a good idea to state what you have told the patient about his or her problem and when he or she is due for review or discharge.

General practitioners can help you too

As we have already said general practitioners hold a wealth of information about their patients and have access to a wide range of resources in the community. Box 6 lists just some of the areas where you might seek information from a patient's general practitioner.

Box 6 - Information available from general practitioners' records Details of presenting complaint Details of previous medical history Medication (recent, past, or illicit) Home/family/social circumstances Existing care packages Contact details of relatives and neighbours

In general the best times to call general practitioners in surgery are mid to late morning or mid to late afternoon. Always give the patient's name before the receptionist puts you through to the doctor so he or she can have records to hand when you talk. If you want to be called back leave your name and bleep number. It should always be possible to speak to a doctor from the practice during surgery hours. Out of hours a doctor will always be on call for the practice but if that doctor is from a cooperative or deputising agency he or she may not have access to the patient records until the next time the surgery is open.

Conclusion--The five C's

Good communication between primary and secondary care should not be difficult to achieve and is worth the small amount of effort involved. Some recent work in the context of HIV/AIDS about the often tricky area between general practice and hospital practice (sometimes called the interface) has highlighted the five C's, which are³:

(1) Coordination
Care is inevitably going to include primary care (the general practitioner) and specialist services (the hospital) especially if the patient has a complex condition, or simply one that requires special expertise. A managed coordinated service is going to be far more effective than one by default, and certainly patients like to see that both sides of the service are communicating.

(2) Communication
This is the whole point of this article! At least one study has shown that letting general practitioners participate actively improves overall care and increases patients' satisfaction.⁴ Once again communication ought to be mutually beneficial, and hence the content of referral letters to the consultant should mirror, in quality at least, the information that is sent to the general practitioner.

(3) Confidence
The confidence of patients and their general practitioners will be best served when hospital services fully support local general practitioners. One of the challenges with patients who have special conditions (for example, HIV infection) is that general practitioners never acquire enough experience to manage with confidence. Communication and a willingness to collaborate are ways of reducing this potential problem within primary care.

(4) Clinical skills
Communication between hospital and general practice is important not only because it serves individual care but because it provides for opportunities to enhance knowledge of certain conditions. General practitioners especially appreciate this because it provides vital learning that is patient and practice based as well as up to date. No communication is therefore a lost opportunity.

(5) Confidentiality
Confidentiality is so fundamental that any form of communication about patients must take this into account. Often practices will have a policy about confidentiality, and certain conditions (topics such as sexual health are common) invoke a necessary awareness of the subject. One area of interest in both hospitals and the community is the use of computers. These certainly improve audit and monitoring, but clinicians need to be aware that patients may regard their ability to store and transmit data as a two edged sword.