Out-of-hours special patient notes

Key messages

Special patient notes (SPNs) provided by in-hours general practitioners (GPs) to out-of-hours GPs improve the care of patients who have long-term conditions. In-hours GPs responded very well to targeted requests by the out-of-hours service to provide or update SPNs when patients needs arise. The SPN system needs to continue, with ongoing prompts to day-time GPs to provide up-to-date information. The system needs to be integrated with Coordinate My Care and similar systems that help professionals to co-ordinate their activities.

Why this matters to us

We are passionate about communication between day-time and out-of-hours health professionals. Our work in developing out-of-hours services has made it clear to us that good communication results in better patient safety, easier management of patient problems and more satisfying clinical encounters.

Abstract

In 2011, an out-of-hours service in central London reviewed its system for special patient notes (SPNs) – a main mechanism to communicate valuable information about patients to the clinicians who cover two-thirds of the week when day-time general practices are closed. This revealed that:

• half of frequent callers did not have an SPN

• about half of existing SPNs were out of date

• day-time general practitioners (GPs) respond well to requests by out-of-hours doctors to provide an SPN

• providing SPNs was low on the list of priorities of day-time GPs who were too busy reacting to everyday problems.

Introduction

The New GP Contract of 2004 allowed general practitioners (GPs) to opt out of 24/7 cover for their patients. This means that for two-thirds of the time (night-time, weekends and bank holidays), patients who need help encounter doctors and nurses who do not know them – potentially fragmenting care. Typically, a patient will call their GP surgery and be advised to call ‘111’. The 111 operator uses a set of protocols to help these patients, and some will be forwarded to the GP out-of-hours service for a further telephone consultation to decide if an emergency face-to-face consultation is needed.

The lack of knowledge about a patient often does not affect practical management (although it may affect use of the health service and therefore overall cost). For patients who need continuity and home visiting, however, it can make a big difference.^1,2 Thus, care plans for patients with long-term conditions and complex needs, as well as those receiving palliative and end-of-life care, need to be communicated to out-of-hours GPs. This has considerable advantages, including avoiding unnecessary hospital admissions, building trust in the system as a whole, and heightened sensitivity to patient and carer anxieties and intentions (for example, if a patient does not want to be resuscitated should they collapse).^1,3,4

Special patient notes (SPNs) are the main way for day-time GPs, who are the co-ordinators of their patients' care, to communicate this information to out-of-hours doctors and nurses. They are brief summaries of key information that help out-of-hours clinicians make good decisions. They include care plans, patient wishes and particular insights that come from knowing someone well. They can be seen and accessed immediately by both the operator and clinician when a patient calls.

The London Central and West Unscheduled Care Collaborative (LCW) provides out-of-hours primary care services to 800 000 patients across four primary care trusts (Brent, Hammersmith & Fulham, Kensington & Chelsea and Westminster) offering GP telephone advice, GP surgery consultations and GP home visits. Building from a 2007 study into communication between day- and night-time practitioners for end-of-life care, in 2011 LCW re-examined the SPN system.⁵ The following four connected audits were conducted:

• review the needs of frequent callers for an SPN

• systematically identify other patients who need an SPN

• review the quality of existing SPNs

• obatin qualitative feedback from practices that were high users of the SPN system.

The results and implications of these audits were then reviewed as a whole by the investigating team, at an educational event and by the clinical governance group, to discern the implications for policy, mindful of the development of Coordinate My Care (see related article in this issue of LJPC).

Methods

Review the need of frequent callers for an SPN

A four-month (March, May, June and July 2011) review of frequent callers, defined as a patient calling more than five times in one calendar month, was conducted by searching the Adastra database. The clinical record was reviewed for each frequent caller to identify the primary problem for the patient, and whether the patient had an existing, up-to-date SPN. A letter was devised and sent to the patients' registered GPs requesting an SPN for those who did not have one.

Systematically identify other patients who need an SPN

Over eight and a half days, all out-of-hours GPs were asked to identify patients who would have benefitted from an SPN. A pop-up window (see Box 1) was designed in Adastra to appear after the clinician closed the consultation. It was proposed that this would trigger a letter to the day-time GP requesting an SPN, or an update of an existing one, where relevant.

Box 1. Pop-up window.

Would you like us to ask the patient's GP for a special patient note (SPN*) for the benefit of future LCW consultations?

(Pull-down menu):

Yes: an SPN would help future consultations.

Yes: we have an SPN but an update would be helpful.

No: SPN not needed for this patient.

No: we have an adequate SPN for this patient.

No: we have an SPN but it is now obsolete.

If yes, what information in particular would future LCW doctors find useful when managing this patient?

(Optional free text box to answer in)

Review quality of existing SPNs

At the time of the study, there were 1200 SPNs – approximately 900 attached scanned documents and 300 typed ones. We randomly selected 20 of each to assess their usefulness, in respect of:

• out-of-date or incorrect information

• expiry date having passed (usually six months)

• category of SPN (for example, child protection, end-of-life care)

• usefulness to out-of-hours clinicians

• other things that seemed to offer new insights.

Qualitative feedback from practices that were high users of the SPN system

The six GP practices that provided the most SPNs were contacted to ask how they thought the system could be improved.

Results

Review the need of frequent callers for an SPN

Forty patients called more than five times in the four months analysed. They generated a total of 284 calls in the four months audited and resulted in 58 visits. Of these, 23 (57.5%) had mental health problems, and 17 (42.5%) were stated to have purely physical health problems, including palliative care.

Thirteen (32.5%) of the frequent callers already had a useful and appropriate SPN and four (10%) did not merit an SPN because their calls had been for an acute medical problem. The remaining 23 (57.5%) lacked an SPN.

The 23 GPs whose patients needed an SPN were sent a letter in July/August requesting one. Fifteen GPs responded to this straight away by writing an SPN. Eight patients were left without an SPN at that stage. Letters to those eight GPs in October resulted in six more SPNs. This left only two without an SPN.

Systematically identify other patients who need an SPN

An analysis of out-of-hours GP SPN requests was conducted; of the 45 ‘yes’ responses during the Adastra pop-up trial, 36 (80%) requested a first SPN (there already were SPNs for four of these patients) and 9 (20%) requested an update to an existing SPN.

Thirty-one (69%) GPs gave a free text response to the question of what background information would have been useful. A qualitative and subjective assessment of these yielded the following analysis: 5 (16%) simply described the consultation that had taken place; 14 (45%) asked for information that is already asked for on the SPN form; and 9 (29%) asked for useful additional information.

Review quality of existing SPNs

From the 1200 SPNs, a sample of 40 were reviewed. For 24 of these (60%), the expiry date had passed. The remaining 16 (40%) were up-to-date. The majority of SPNs (23; 57.5%) related to palliative patients, ten (25%) related to a child protection concern, two (5%) related to patients with multiple aliases, two (5%) were mental health related, and the remaining three referred to a drug-seeking patient, an acute illness and a patient with chronic complex medical problems.

The clinical details were not current in 16 (40%), and were current in 8 (20%). Only five (12.5%) were considered to be fully helpful to the out-of-hours GP. When considering the quality of the content alone (disregarding whether the information was sufficiently up-to-date), the majority (35; 87.5%) were considered adequate for the purposes of LCW's clinicians.

Other comments

• The child protection SPNs merely stated the category of Child Protection order, and sometimes the name of the social worker. There were no further details that might have helped.

• One SPN dated from 2002 and one from 2005.

• One included a community mental health team letter that was particularly useful.

• One palliative care SPN was simply a discharge summary from hospital which omitted useful details such as patient's preferred place of death.

• Three referred the reader to other documents.

Qualitative feedback from practices that were high users of the SPN system

The six practices that provided the highest number of SPNs were interviewed over the telephone about their views of the SPN system. They all expressed the view that they had so much urgent work to do that providing SPNs to LCW, although important, was low on their list of priorities. To improve the rate at which SPNs could be provided, the system needed to be made more user-friendly for GPs.

Discussion

This study reminds us that to do their job well, out-of-hours GPs need accurate and up-to-date information about patients with long-term conditions and those who are frequent callers. The SPN system is one main mechanism to do this, especially for patients who are not included in the Coordinate My Care register (for people considered to be at the end of their life). Out-of-hours services need to systematically maintain and improve the SPN system.

The study also highlights that day-time GPs are willing to provide an SPN when prompted by out-of-hours GPs. Such prompting should become standard practice. Further work is needed to establish whether such prompting also needs to be accompanied by education and guidelines for GPs to help them to identify patients who would benefit from an SPN, and how to make and update an SPN.

The advent of Coordinate My Care for patients in their last year of life presents opportunities and threats for the SPN system. There is need to pilot ways to integrate the two systems.

The study highlights the potential for out-of-hours services to contribute to integrated care, including containing costs by avoiding hospital admissions. These services cover two-thirds of the week and could generate data that informs strategy for whole system improvements as well as improvements in the care of patients who have SPNs.

GOVERNANCE

This work was overseen by the LCW Clinical Governance Group.