Continuing care

Single condition pathways are often not appropriate for patients with more than one condition.


Super specialists may not understand the implications of their recommendations on other conditions.


Internal referrals or between specialists save time and avoid the need for patient to return to GP.


Internal referrals without reference to the GP may cause duplication of effort.


Patients are requested to follow up with GP before that has been agreed between specialist and GP. There may be failure to provide advice to GP or to indicate under what circumstances the patient should be referred back. Patient is left unsure who they should be contacting.


Some shared service pathways are developed without GP input or without agreed resource for primary care.


Lack of timely communication between health professionals when the patient’s condition is changing (eg during cancer treatment) can lead to uncertainties as to what the current treatment should be.


Patients are sometimes discharged home at short notice who have significant continuing care needs. It can lead to disruption to a general practice in ensuring a care package is in place.


There may be a lack of clarity as to who is responsible for ensuring advance care plans are in place for palliative care in the community.


It may be unclear who is responsible to whom for death notification. This may cause distress for carers and staff if inappropriate messages or contacts are made.