Bungay Medical Practice is a busy GP practice in Suffolk. Over the past five years the practice team has developed a follow-up process for all patients discharged from hospital which has helped to improve continuity of care and patient experience, while also avoiding unnecessary readmission and medication error.

Being discharged from hospital can be a difficult time, especially for frail older patients who are less able to coordinate their own care. With changes to medication made when patients are in hospital and the need for follow-up care from many different organisations once the patient gets home, there are many points in the pathway with the potential for error or risk to a person’s health.

The team at Bungay Medical Practice first introduced their protocol for proactive follow-up after hospital discharge over five years ago, and it has now become firmly embedded in everyday practice.

Over the years the practice has trialled several different methods of follow-up with patients. Initially, a practice nurse was allocated a weekly session to contact patients, as it was assumed that follow-ups would need to be coordinated by a clinician. However, the team quickly realised that the reception team were better placed to provide a more responsive follow-up service, with the time and resources to contact patients as soon as discharge information is received from the hospital.


“When we receive a discharge summary from the hospital we’ll contact the patient by phone. This is to book any follow ups that are required (blood tests, doctor appointments, home visits etc), but also just to see how they’re feeling on discharge. Some patients, particularly our older patients, come out feeling quite unwell, physically but also emotionally. They’re vulnerable and scared. We check whether there’s anything we can do to help and reassure them.”
           Bev Tooley, Reception Manager
  • All patients are contacted by telephone within one week of hospital discharge by a member of the reception team.
  • The team can coordinate input from the practice. Clinical and medication needs are assessed over the phone and any issues or queries are passed on to the GP or community matron to follow up.
  • Any necessary follow up appointments or home visits from practice staff are booked and arranged.
  • The team can also connect the patient up with services outside the GP surgery, including the district nursing team and social care.
  • Where necessary, they will also check that the patient knows to book a follow up hospital appointment, and in some cases will help to do this.
The team report many cases where the follow up phone call has picked up something small which could have quickly escalated resulting in the patient becoming very unwell. In some cases a doctor is sent out to the patient’s home the same day.
  • Improved patient wellbeing and good patient experience: Feedback shows that patients really like the service, and are reassured that they do not have to wait for a GP appointment to sort out issues relating to discharge.
  • Avoiding medication error: Picking up issues with stopped or changed medication at an early stage avoids any serious health implications and helps medication to be administered more smoothly. The process also reduces stress for patients who have had medication stopped whilst in hospital.
  • The full picture: The follow up call following discharge enables the clinical team to quickly discover the ‘whole picture’ about a person’s hospital stay and follow up needs, before memory fades.
  • Fewer readmissions to hospital: Although the team can’t provide data about reduced readmissions, they know there are many occasions where issues have been dealt with in the community due to their follow up protocol, avoiding escalation to emergency care.
  • Improved team working within the practice: Involving the admin team in the coordination of follow up has encouraged a team approach to problem solving and improved communications within the practice.
‘We always get good feedback from patients. We have quite an elderly population and they feel it’s like the old fashioned GP care where someone is looking out for you when you come out of hospital. It’s a more personal and human approach – there’s someone checking you’re ok. It also prevents a lot of extra correspondence and queries going back and forth to the hospital because we’re able to deal with things here. A lot of patients don’t want to be a bother, but we often think “thank goodness we rang you”, if not they might have been two or three days without tablets and it could have been a lot worse.’
           Lisa Townsend-Kwan, Deputy Practice Manager at Bungay Medical Practice

Spend time building good relationships with partners and stakeholders: Building good relationships with the two main hospitals in the area has been essential, especially when the team needed to address the slow handover of discharge information from one hospital. Constant communication between the clinical leads from the practice and the hospital has helped to solve this issue and the team are now receiving electronic discharge summaries on the day of discharge.

Trust your team to try new things: Entrusting the administrative team with this important liaison role has really paid off and frees up clinical time and resources.

Be willing to keep changing things until you find an approach that works: Over the years the practice has trialled several different methods of follow up with patients, trying new approaches until they found one that felt right

A whole team approach can lead to more creative problem solving: The practice holds a weekly team meeting with all clinicians and representatives from the admin teams. Issues flagged as part of the discharge follow up can be raised and discussions benefit from multiple perspectives and a team approach to finding solutions.

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