Improving the continuity of care between general practitioners and public hospitals.

OBJECTIVE: To improve the quality of clinical care through better continuity of services between the public hospital and general practitioners (GPs), focusing on expediting discharge of patients from hospital through improved use of resources provided by GPs.

DESIGN: Stage 1: Participant observation during ward rounds and unstructured interviews to gain an understanding of the perceptions of hospital staff and GPs of the GP's role in the discharge process. Stage 2: Semi-structured interviews with registrars and GPs of 30 patients (who were admitted to a medical ward and discharged to the care of their GP) to get the participants' views of each other's roles in providing continuity of care.

RESULTS: There was a general lack of trust on both sides, and poor communication owing to several structural and perceptual problems. Registrars focused on specialist care and outpatient follow-up, being almost oblivious to GP functions, apart from monitoring the management plan developed in the hospital; they made no use of GPs' knowledge of the case or their experience in treating patients within their families and social milieu, and frequently wished to do everything within the hospital. GPs, on the other hand, often felt alienated from the hospital system, although they had much to offer by being able to contribute details of the patient's background and by using their special skills, which went well beyond passively monitoring progress.

RECOMMENDATIONS: 1. Information about the patient's GP should be made available to hospital staff. 2. Interns should make telephone calls to GPs after admission and when the discharge date is known. 3. Early-discharge summaries should be forwarded and include: (i) reasons for giving or altering medications; (ii) specific plans after discharge; (iii) information conveyed to the patient and family about the illness; and (iv) a summary of the case by the consultant. 4. Registrars and interns should be educated about the appropriate involvement of GPs in the discharge process and throughout the patient's stay in hospital. 5. Direct involvement of the GP with the patient during hospital stay should be encouraged. 6. A pilot study should be set up to investigate the role of a liaison person in overcoming problems of the transition of care of hospitalised patients to the community.