Summary

This outcome is about ensuring that there is a delivery of safe and coordinated care when patients move between providers or receive care from more than one provider.

Outcome in plain English

6A Transfer between services

  • There should be a main person responsible for overall coordination
  • The patient should have the name and contact details of the lead
  • The treatment plan should include details of transfer arrangements
  • There must be an accountable person/agency for each of the needs

People involved in the care of the person should:

  • Co-operate
  • Have documented plans
  • Have relevant medical and other notes
  • Each person must properly record treatment provided
  • Have all information readily available

6B Information passed to another provider

  • Include all relevant information about the patient to treat the patient safely. The prompt lists items as a minimum requirement for information to be provided.
  • Make sure information is transferred in a timely manner
  • There should be no interruptions to continuity of care

6C Organise yourself so that:

  • One service provider has the lead coordinating role
  • The other providers should know who this is
  • All the providers should be involved and kept up to date in the treatment planning
  • Discuss the plan with the patient

6D Major incidents and emergencies

  • There should be a coordinated plan for major incidents and emergencies between the providers
  • Be prepared for civil emergencies
  • Monitor and review these plans as a coordinated provider group

6E Transfer of information

  • Maintain patient confidentiality
  • Information transfer is secure
  • Agree in advance all information transfer protocols between providers
  • Staff are aware of these protocols

Information transferred should be:

  • Relevant
  • Factual and correct
  • Is allowed to be shared by Data Protection Act 1998 and other guidance.
  • Staff notify the manager if there has been an information security breach

You must have procedures to deal with information security breaches, and these procedures should include

  • Informing the patient of the breach
  • Get patient permission if the information needs to be disclosed for public interest
  • If patient consent is unobtainable; have clear reasons for your disclosure.
  • Respect patient rights

6F The patient knows who to contact if their needs are not being met

6G The patient or the carer/guardian should know what information about them is being transferred and should be given a copy if requested

6H Transfer of information to another service

  • Relevant information must be transferred to another service, unless there is a good reason not to.
  • There reasons must be explained to the patient

6I Informing the patient of services available

  • Tell the patient of health and social care services available to them
  • Help them to make referral decisions
  • Enable access to these services as long as their care is not compromised

6M Children moving on to adult services

  • All providers should cooperate to ensure continuity and appropriateness of services to the age of the patient
  • Children and their guardians are involved and kept informed

 

What the BMA says

Your practice is likely to be compliant if your practice does the following:  

  1. Discusses with patients the options and arrangements for referral  
  2. Includes in correspondence all of the information that would reasonably be required to treat the patient safely and effectively. For example:
  3. the patient’s name, gender, date of birth, home address and NHS Number, where known;
  4. if applicable, the name and contact details of the patient’s representative;
  5. relevant information about the care and treatment provided to date;
  6. relevant medical history, allergies, prescribed drugs and patient preferences;
  7. infections that need to be managed (if relevant);
  8. the reason for the referral and what is required;
  9. By whom the referral is made and, where different, the person to contact in your practice about the patient and their contact details.
  10. When a patient leaves your practice, transfers the relevant information to the new provider(s) in a timely manner so that the needs of patients can be met in an appropriate timescale
  11. In the case of children and patients without the capacity to give consent, ensures that their parents/guardian/representatives are involved and informed about referral decisions.
  12. When referring patients, ensures that patients know at least what type of information is being transferred.   
  13. Respects the right of patients to request information about them to be transferred to another provider unless there is a good reason for not doing so.   

Your practice has the following:

  1. An emergency preparedness plan including arrangements for sharing information and working with other providers. In the BMA/RCGP/DH’s pandemic flu guidance there are model arrangements for working with other providers during long term incidents e.g. a buddying-up system.
  2. When cooperating with other providers/referring patients, arrangements that ensure that information is transferred and received safely and securely. To underpin this we suggest that you have a confidentiality protocol/information governance protocol that refers to information disclosures.
  3. A protocol for acting on correspondence and results, to ensure that your staff are able to respond in a timely manner to incoming information.

Primary Care Networks (PCNs)

Partnered with the NAPC, the largest PCN network in England

 

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