Macmillan cancer experts Steven Beaven, Cathy Burton and Lorraine Sloan talk through their recent ‘A Day in Each Other’s Shoes’ initiative to explain how it helped professionals in primary and secondary care understand more about the importance of good communication
Dr Steven Beaven, Dr Cathy Burton, GP Advisors, Macmillan Cancer Support
Lorraine Sloan, Medical Communities of Influence Lead, Macmillan Cancer Support
Poor communication is a consistent and concerning theme for patients, often resulting in complaints to the practice or, in particularly serious cases, events that prompt significant analyses.
Problems about communication between different care sectors are also a regular feature when groups of clinicians discuss their work. In primary care, we will comment on the delayed discharge letter or if we are not notified about the death of one of our patients. Secondary care clinicians will have their own stories of the shortcomings of communication from primary care.
Older GPs are likely to remember the days when they knew or had closer contact with their consultant colleagues in the local hospital, but this relationship appears to have diminished greatly, to which a range of factors, including work pressures, increasing specialisation and an increasingly part-time workforce, will have contributed. It seems there is no longer the time, nor the opportunity, for conversations between colleagues.
Effective communication is of particular importance in relation to patients affected by cancer. More than 2.5 million people are living with a diagnosis of cancer in the UK, and this is projected to rise to 4 million by 2030. While it is good news that people are living longer following a cancer diagnosis, many people continue to report poor experiences of care, either as a result of poor communication and coordination at key transition points or due to a lack of aftercare and support as they continue to live with the consequences of their cancer and its treatment.1,2
Macmillan has been testing ways to generate insight and share ideas that will improve communication and care for patients by bringing together health professionals from different care sectors at a series of events. These have helped to create a shared understanding of the different perspectives about cancer care, and to generate a number of suggested small changes to practice that could potentially have a big impact.
To date, seven events have been held across the country involving more than 130 professionals from primary and secondary care, including GPs, cancer leads, consultant oncologists, radiologists and surgeons, junior doctors, and specialists in palliative medicine.
The events have been facilitated by Macmillan’s joint chief medical officers (CMOs), one of whom is a consultant oncologist and the other a general practitioner. They have brought their understanding of the issues which face patients with cancer, especially during key transition points such as at diagnosis, end of treatment and transition into incurable cancer, as well as an understanding of the perspectives that exist across their peer networks in primary and secondary care.
The aim has been to create a safe space for conversation to identify what we call ‘the gobsmackingly obvious’ things that we could all do, without the need for huge system change or investment.
Our CMOs have been supported in this work by a wider team of Macmillan GPs and consultant advisors who continue to facilitate similar events themselves with support from Macmillan.
A number of themes have emerged from the events including:
- Recognising the importance for achieving earlier diagnosis of cancer
- Identifying the need for primary care to have greater access to informal specialist advice and the need for more honest conversations about end-of-life care
- Realising that there is a fundamental lack of understanding about each others’ roles and ways of working as well as imperfections and difficulties in communication.
Additionally, consultant participants noted that their letters to GPs are often written more to themselves for the purpose of updating the hospital notes, than for meeting the information needs of the GP. As one of our GP participants said: ‘We need to walk in each other’s shoes a bit.’
‘A day in each other’s shoes’
A key development to emerge from these Macmillan events has been the concept of shadowing. A number of GPs and consultants have undertaken a Macmillan shadowing day called ‘A day in each other’s shoes’. Participants have reported that they have valued being able to develop personal relationships and to understand one another’s roles much better, resulting in improved communication as well as the potential for effective shared care. Two participants of the shadowing days were Dr Helen Murrie, Macmillan GP cancer lead for Tayside and Dr Caroline Michie, an oncology consultant specialising in breast cancer at Ninewells Hospital, Dundee. Both were struck by the difference in the time each was able to spend with patients, and the contrast in the depth of knowledge required in secondary care versus breadth of knowledge needed by GPs on many different conditions. This highlighted the importance of clear, succinct communication across sectors.
In particular, Helen identified the importance of oncologists being clear about what they need from GPs. “They need to make it obvious to GPs: what’s the plan? What has the patient been told? And what do you want the GP to do? If the directions to the GP are hidden in a three-page document, doctors are much less likely to see it.”
Other interesting insights arising from the shadowing experiences have been the realisation for consultants that GPs actually see patients with cancer relatively infrequently in the surgeries. Also,for GPs, MDT meetings are extremely pressured with just a few minutes allowed for the discussion of each patient’s case.
However, while the experiences of shadowing have been very positive, we recognise that relatively few GPs and consultants will have the luxury of being able to do it themselves. At Macmillan we are exploring alternative ways to improve understanding and communication, including supporting practice nurses and clinical nurse specialists to ‘buddy’, and promoting the sharing between primary and secondary care of mobile numbers, direct lines and email addresses. Longer term we would like to see more experience in primary care for doctors going into specialist training.
Audit of clinic letters
The challenge of communication across sectors was a consistent theme to emerge from most of these Macmillan events. As a result, Macmillan is supporting clinicians to undertake a shared audit of clinic letters to identify what makes a good letter from GPs at the point of referral, and from secondary care at the end of active treatment. The findings will be written up as part of a series of communications aimed at sharing insights from clinicians on key issues related to cancer care.3 Macmillan consultant advisor Dr Richard Simcock is also developing a framework for communication that could form part of the electronic curriculum for postgraduate training. We will be encouraging adoption of this framework by the Colleges as a means of reviewing intra and inter communication.
Macmillan Cancer Support sees this approach to convening professionals who would otherwise rarely or never meet, as an important enabler for change. By developing shared perspectives and potential solutions, testing these amongst local peer groups, and continuing to share and cascade learning, we are also creating a receptive climate for change amongst much wider peer groups of professionals. Macmillan is continuing to work with its network of professionals to tackle some of these issues, and to facilitate change at the local level. We believe this simple and innovative approach to surfacing differences in perspective and working towards shared solutions, could have a huge impact on experiences of care for the growing number of people living with cancer. To find out more about our work, contact us at firstname.lastname@example.org.
2. British Journal of General Practice (2011)
3. Macmillan Ten Top Tips series (http://www.macmillan.org.uk/Aboutus/Healthprofessionals/Primary_care_cancer_leads/Resources.aspx