Communication and a Culture of Change

‘Personal Views on Healthcare in Wales’

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Jane Fenton-May, Royal College of General Practitioners

As I think of the future of medicine, it is difficult not to look back and think how things were. As a clinical student in Cardiff in the early 70s, one knew most of the consultants (the number of which was relatively small), senior lecturers, professors and a lot of the junior doctors as well as the local GPs. Communication in some ways was easier as we felt part of a group working in teams, spending long hours on the wards or in general practice. That was all before the juniors strike, when working long weekends and ‘one in two’ rota were normal.

Over the years the pressures in the NHS have changed.

In the 90’s we had fundholding GPs, plus the purchaser provider split then ‘set’ general practice and hospital services. This was paralleled by a larger expansion of “ologists”. Even in the last 10 years we have seen a 60% increase in consultant expansion while GP numbers have remained fairly stable.

We have broader ranges of investigation and treatments with more complex management regimes often led by small sub-speciality, multidisciplinary teams.

Training has followed need and resulted in prescribed, linked training posts rather than the self-developed almost peripatetic SH – registrar – senior registrar journey of my peers.

Additionally, The EU working time directive prevented the unsafe rotas of the past, but resulted in shift work and loss of supportive teams.

These developments have had profound effects on the way we as professionals interact and communicate. Face to face meetings between GPs and hospital doctors are rare, CPD is more prescribed – specialised or electronic (further reducing social interaction between professionals). Even the interaction between different practices or hospital specialities has reduced, particularly in areas served by larger hospitals compared to the smaller DGHs.

Sadly, as departments have had to endure year on year efficiency savings, they have defined their services and developed restricted pathways often to the detriment of patient care as patients seldom fall into neat boxes or diagnosis.

Patient demand has increased alongside public health knowledge, the internet and the developments in medication, surgical innovation and technology.

90% of patient clinical interaction occurs in general practice. The numbers of consultants alongside their workload and pressures has increased greatly, whilst the ‘personal’ secretaries have been in some areas replaced by teams of booking clerks and typing pools or even computers.

Having had a portfolio career working in a variety of GP posts in practices across south east Wales including locum, assistant, salaried to LHB and partner for 40 years, as well as having worked in the All Wales Genetic service for 20 years as a clinical assistant and then as an Associate Specialist, I have seen the interface in multiple settings and from both sides and how it has altered. The impact of the intervention of technology has been vast; electronic referrals and result reporting are now universal; dependency has been generated for electronic communication between hospital and general practice, perhaps at the expense of personalisation.

Getting hold of people by phone is increasingly difficult, all whilst management and administration staff numbers have increased with systems and pathways having been developed from the viewpoint of the department rather than the whole NHS service or the patient.

Last year Dr Chris Jones, then acting CMO Wales spoke to the Academy of Medical Royal Colleges Wales about his concerns regarding professional behaviours across the primary and secondary care interface.

Aware of the risks to patient care and the significant incidents occurring across the interface to the detriment of patients’ health some of which were recorded (some not), I was anxious to take this work forward.

As a result I consulted a broad range of professionals across Wales both on a formal and an informal basis, collecting information about concerns. It became apparent that the issue was not just between GPs and secondary care but also between different parts of secondary care – different departments, specialities and even different hospitals and the same speciality – as well as secondary care, tertiary or out of area care including England.

We were asked to identify the problems, this was the remit of the report; I acknowledge that this does look like a list of moans with the majority from general practice. I’ve endeavoured to make some of the problems more generic as they often were echoed from both sides of the seeming divide, especially if you incorporate cross speciality and hospital communication.

In both the Focus Group and at Academy council it was agreed that we need a culture change more than anything else. We need to learn to respect other professionals of all grades and to realise that we all have different expertise and service pressure, which impact on the patient journey and health care.

The next step is to look at how we can change some of the systems to improve the behaviours and professional communication particularly between doctors.


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