Lay member, Academy Medical Royal Colleges, London, UK
Received date: 17 June 2004; Accepted date: 23 June 2004
There have been few articles in this journal on the importance of diagnostic services in primary care. From the patient’s perspective, quality in primary care also means that the general practitioner (GP) has access to accurate and timely laboratory services. The numbers of tests being ordered by GPs is rising and nurses are now involved in requesting laboratory investigations.
Patients assume that laboratory investigations will be accurate. However, it is unlikely that many patients know the nature of the test, or the investigation to be carried out on the sample being taken, or who is responsible for carrying out the work. Patients are not infrequently told ‘we shall do some tests and send them to the lab’. For example, when a blood or urine sample is taken, the patient is not necessarily told what specific tests are being requested; and equally important, patients are not necessarily told what the pathologist found. Patients may have to assume that ‘no news is good news’. They may be told that the ‘results’ appear ‘all right’, or that more ‘investigations’ are needed or perhaps that there is a ‘specific problem’. None of these terms are helpful in keeping the patient informed about what is happening to them or in informing them about the work of the pathologist who is also involved in their care.
Over the last 100 years, the pattern of disease has changed dramatically. Improved living standards, better nutrition, and effective drug and immunisation therapies have meant a decline in acute infectious diseases. These have been replaced by chronic conditions such as cancer, coronary heart disease, strokes, mental health problems and Alzheimer’s disease. The result being that many patients have had to learn to live with chronic and degenerative disease. Additionally, a great majority of these patients now receive their health care in the community. Patients with chronic conditions have many tests to monitor their illness and guide their treatment and when there is an acute illness or an acute episode, frequent and complex investigations and tests are likely to be arranged. Therefore, for patients the link between pathology and primary care is extremely important.
Many patients have experienced the complexities of out-of-hours services in general practice. However, few will have considered the difficulties surrounding the reporting of abnormal laboratory test results to primary care out of hours. The request for investigation bears the contact details of the referring GP but not of the patient and deputising services do not currently have access to patient notes. Staff at the deputising services, who do not know the patient, may not appreciate the importance of the abnormal result. They may not be willing to accept responsibility for a result that was generated through a request made by the GP or other appropriate primary care staff member within normal working hours. While serious abnormal results that need to be acted upon cannot always be anticipated, the patient is unlikely to:
• know what investigations are being carried out
• be asked by primary care staff how they could be contacted out of hours
• be asked by primary care staff to contact the deputising service directly to ascertain the result.
It is clearly essential that when an abnormal result is identified out of hours and treatment or further investigation is required, that contact can be made with the patient. However, consideration needs to be given to confidentiality and data protection, particularly if the patient’s telephone number were to be included on the request slip. The patient would need to agree to have their telephone number on the slip. Beastall suggests that in future all laboratories will need to have an agreement with their local primary care trusts of the detailed procedures for the reporting of abnormal results out of hours to protect patients. However, the problem of speedy information out of hours from the laboratory to the deputising services may eventually be solved when the electronic patient record is operational.
Doctors and now nurses need access to accurate and high quality laboratory services. Requests to laboratory services for investigations always come from professional staff. Patient centred care in the community could involve the patient or their carer requesting an investigation. It could well be convenient and appropriate for ‘expert’ patients involved in the management of their own chronic condition to request specific investigations from the laboratory. The Expert Patient Programme sets out a vision of a programme to increase the capacity of patients with chronic illness to access health and social care services effectively, to increase their knowledge about their condition and its treatments, and to help them spend fewer days in hospital and doctors consulting rooms. A further aspect of the informed or expert patient is that patients with, for example, HIV or cancer need to know that their tissue samples are kept and that they can request further tests to be done on them, as tests or treatments that are dependent on newly discovered or developed histological, immunological or biochemical factors come along. Patients need this information to protect their own interests. The expert patient programme gives control to the patient, and in addition there is evidence that expert patients probably receive fewer and higher quality consultations that are satisfying both to doctor and patient, and save GP and patient time.
Quality also involves educating the public about pathological investigations as well as informing individual patients about the nature of the investigation. The patient may be told what the investigation is for, but the tests or investigations themselves are seldom described or explained to the patient. There are several possible explanations for this including paternalism or the belief that technical matters need not be talked about or simply that that ‘the patient would not understand’. In addition, there is now the very real problem of shortage of consultation time in general practice. Nurses may not have sufficient knowledge to discuss technical matters with the patient, and pathologists have not necessarily provided the appropriate information for primary care staff to give to patients. The Royal College of Pathologists has produced a variety of useful information leaflets for patients and the public, including an excellent recent one on allergies and plants to avoid growing in a low-allergen garden. Most of this information can be accessed electronically and could be given to patients in consultations or displayed on practice noticeboards.
Patients and those looking after them in primary care need access to quality pathology services. As practices devolve out-of-hours work to deputising services, reliable systems need to be established to ensure that the patient can be alerted when an abnormal result requires immediate attention. Doctors and nurses have a professional obligation to explain to patients the nature of investigations to be carried out and the work of the pathology services.