How standardisation has improved service delivery

As the near-exclusive format of discharge communication to primary care in the NHS, discharge summaries hold a critical role in patient safety and quality of continuing care (Healthwatch England, 2017; Spencer et al., Reference Spencer2018). The necessity of their timely delivery to primary care has been clearly highlighted (Kripalani et al., Reference Kripalani2007), and the electronic delivery of summaries within 24 hours of discharge is now a contractual obligation (NHS England, 2016). The quality of content is also vital (Patterson, Reference Patterson2008; Tandjung et al., Reference Tandjung, Rosemann and Badertscher2011; May-Miller et al., Reference May-Miller2015; Caleres et al., Reference Caleres2018), and the last two decades of policy and improvement work have centred on setting information standards (Carpenter, Reference Carpenter2008; Academy of Medical Royal Colleges, 2008; NHS Digital, 2017a, 2017b; Professional Records Standards Body, 2018) and using summary templates with corresponding headings to deliver them. In the UK, these standards are highly generic and designed to be applicable to any patient (Professional Records Standards Body, 2018), with quality typically measured by adherence levels (Hammad et al., Reference Hammad2014; May-Miller et al., Reference May-Miller2015; O’Connor et al., Reference O’Connor, O’Callaghan, McNamara and Salim2018; Scarfield et al., Reference Scarfield2022). Incomplete handovers can be associated with higher risks of medication errors (Bergkvist et al., Reference Bergkvist2009), deterioration in chronic conditions (Humphries et al., Reference Humphries2020), readmissions (Al-Damluji, Reference Al-Damluji2008), and death (Kripalani et al., Reference Kripalani2007; Schwarz et al., Reference Schwarz2019; Humphries et al., Reference Humphries2020); standards and templates aim to reduce these with specific guidance for authors. Higher compliance with standards has received positive feedback from GPs as end users both in the UK (May-Miller et al., Reference May-Miller2015; Weetman et al., Reference Weetman2021) and internationally (Van Walraven et al., Reference Van Walraven1998; Kripalani et al., Reference Kripalani2007; Dean et al., Reference Dean2016; Gilliam et al., Reference Gilliam2017).

The limitations of standardising discharge summaries

Despite significant benefits, concerns have been raised about the suitability of these generic content standards to serve all patient cases and optimally drive the quality and utility of discharge summaries from all perspectives (Boddy et al., Reference Boddy2021). Adhering to standards may not fully align with other validatory metrics of quality, such as the notions of a successful discharge summary (Weetman et al., Reference Weetman2021) and the guarantee of episodic continuity of care(Braet et al., Reference Braet2016). These highlight that standards do not fully address other factors such as clarity of language (Weetman et al., Reference Weetman2021), document structure (Spencer et al., Reference Spencer2019; Tesfaye et al., Reference Tesfaye2023) (which is instead determined by local IT software capabilities), and the inclusion of tailored condition-specific information (Gusmeroli et al., Reference Gusmeroli2023) (such as creatinine trends in acute kidney injury). Broadening the requirements for discharge summaries to address these issues raises the challenges of deciding what is relevant to include within free text fields (Wimsett, Harper and Jones, Reference Wimsett, Harper and Jones2014) such as the clinical narrative (Professional Records Standards Body, 2018), and how to use an appropriate degree of detail. GPs criticise summaries for missing relevant content (Yemm et al., Reference Yemm2014) but also describe the negative effects of including excessive, irrelevant, non-tailored information (Hopcroft and Calveley, Reference Hopcroft and Calveley2008; Mahfouz et al., Reference Mahfouz2017; Chatterton et al., Reference Chatterton2024) which can hide important points and consume clinician time. This subjective challenge of deciding what information is relevant is compounded by the different perspectives on quality of primary and secondary care (Yemm et al., Reference Yemm2014; Weetman et al., Reference Weetman2021), meaning that quality of interprofessional communication has become difficult to consistently define (Wimsett et al., Reference Wimsett, Harper and Jones2014; Sorita et al., Reference Sorita2021).

In combination, these issues undermine standardisation of discharge summaries as the panacea for improving interprofessional knowledge exchange at hospital discharge (Wimsett et al., Reference Wimsett, Harper and Jones2014; Boddy et al., Reference Boddy2021), particularly given the increasing numbers of patients who have complex health problems such as multimorbidity (Faitna et al., Reference Faitna2024), polypharmacy (Moriarty et al., Reference Moriarty2015), and multidisciplinary care (Stokes et al., Reference Stokes2016). Patients with higher complexity are recognised to increase the difficulty of discharge communication: stressing the importance of adequate detail from the recipient primary care perspective and making it harder for hospital authors to curate the necessary level of detail (Boddy et al., Reference Boddy2021). The risk of error can also increase (Boddy, Reference Boddy2019), and in the event of suboptimal communication, more complex patients may be at higher risk of avoidable harm (Das et al., Reference Das2018). This is concerning, as standards and templates can become less supportive as complexity increases; the patient’s care may not ‘fit’ them (Boddy et al., Reference Boddy2021). Higher complexity cases therefore expose an ‘Achilles heel’ in the standardised status quo, with potentially greater risks to patient safety and quality of continuing care.

Using a purpose-driven approach to mitigate the limitations of standardisation

To mitigate the limitations of information standards and summary templates, it has been argued (Boddy, Reference Boddy2019; Boddy et al., Reference Boddy2021) that discharge communication should become more tailored to the individual patient and orientated to their post-discharge care. To achieve this, a purpose-driven approach (Boddy et al., Reference Boddy2021) has been proposed, where discharge summary authors are encouraged to look beyond the standardised template headings and focus more explicitly on the foreseeable purposes the document will serve. As Figure 1 illustrates, elements of information (such as those within the Professional Records Standards Body standards (Professional Records Standards Body, 2018)) will serve variable purposes. By considering the relevant purposes involved, authors can tailor the detail of each element to that task (Figure 2). A typical example of this would be providing details about fluid balance and the trajectory of diuretic dosing used during admission, to support a GP to review the patient’s diuretics post-discharge. Similarly, if asking a GP to review benzodiazepine use in a patient discharged to a care home with persistent signs of hyperactive delirium, details could be provided regarding the frequency and dosages required during the admission. Without considering these future post-discharge tasks, authors might consider such information to be irrelevant and consciously exclude it. The recipient GP would then be unable to take advantage of existing knowledge that could improve safety, reduce the risk of falls (if a previous diuretic or benzodiazepine dose was previously excessive), and maximise symptom control (if a previous dose was inadequate). Concisely presenting this information in a discharge summary would also be significantly more efficient for the GP to read, when compared to trawling through extensive shared medical records, which are used in areas such as Uppsala in Sweden (Tully et al., Reference Tully2013).

Figure 1.

The purposes of interprofessional communication to primary care at discharge (adapted from Boddy, Reference Boddy2019 and Boddy et al., Reference Boddy2021) Clinical Information elements within a discharge summary serve specific purposes. Some purposes are ‘constant’ and universally applicable, whilst others are dependent on the individual case.

Figure 2.

A driver diagram illustrating a ‘purpose-driven’ approach to interprofessional discharge communication (Adapted from Boddy, Reference Boddy2019 and Boddy et al., Reference Boddy2021): By first considering the relevant purposes of the discharge summary for the individual patient, the author can tailor the detail of informational elements to serve post-discharge outcomes.

Bringing theory to practice: the need to understand the recipient perspective

Focusing on purpose in this way is in keeping with broader communication theory such as Berlo’s Process of communication (Berlo, Reference Berlo1960), which indicates that purpose is central to effective communication. Building on the classical theories of Aristotle and Faculty Psychology, Berlo states that ‘the purpose of communication is to influence: to affect with intent’. He further remarks that ‘we can often lose sight of our purposes for communicating’, to the detriment of efficacy. This underlines that if a discharge summary author completes the template headings, without consideration of the purposes the document will serve for the individual patient, then quality is likely to suffer.

Berlo’s theory also highlights the equal importance of the recipient’s purpose in a communication process, and that if the purpose of the ‘receiver’ is not compatible with that of the ‘source’ (i.e. the author), then communication breaks down. The different perspectives and purposes that primary care recipients and secondary care authors may bring to the discharge communication process are analogous to this principle, as demonstrated by a recent study that found GPs and hospital doctors disagreed whether a discharge summary was successful in 44% of cases (Weetman et al., Reference Weetman2021). Neither perspective should be considered ‘wrong’, but in line with Berlo’s theory, mutual compatibility of purpose must be maintained for communication to be effective.

In the context of improving discharge communication, author understanding of the recipient GP perspective has already been described as a barrier (Yemm et al., Reference Yemm2014). Hospital doctors have been shown to lack insight into the nuances and practicalities of community care (Wills et al., Reference Wills2011; Yemm et al., Reference Yemm2014; Jones et al., Reference Jones2015; Kable et al., Reference Kable2018), meaning that if a GP asks a hospital author to ‘imagine you’re me’(Chatterton et al., Reference Chatterton2024) when completing a summary, they may not be able to do so accurately. Anticipating the purposes that GPs will use information for may therefore be very difficult. Natural opportunities to improve this interprofessional understanding are significantly limited by the largely one-way structure of NHS discharge communication system, where hospital discharge summary authors very rarely receive feedback from their recipients, if at all (Boddy et al., Reference Boddy2021). Existing national standards (Professional Records Standards Body, 2018) and educational packages such as the Royal College of Physicians learning resource (The Royal College of Physicians, 2018) do not directly address the risk of communicating with ‘misaligned purposes’, further compounding the issue.

The patient perspective

Discharge summaries should also be offered to patients (Weetman et al., Reference Weetman2021; NHS, 2023). A recent realist evaluation found convincing overall benefits of doing this, with clear improvement of patient health literacy, satisfaction, and empowerment, even if technical information is used (Weetman et al., Reference Weetman2019, Reference Weetman2020; Weetman et al., Reference Weetman2021). Such technical information may be incomprehensible to patients and their carers (Harris et al., Reference Harris2018), but its use was regarded as an ‘inherent need’ by GPs, and hospital doctors expressed that oversimplification can reduce quality from the interprofessional perspective (Weetman et al., Reference Weetman2020). This indicates that patients and professionals are likely to have significant differences in their needs from discharge summaries and in the purposes that they use them for. The important task of meeting these potentially contrasting needs with a single summary may therefore be extremely difficult to consistently achieve. This may be particularly challenging for patients who have complex care, when technical explanations and terminology may become even more important for GPs to receive. The tailoring of purpose-driven discharge summaries should therefore extend to include the technical level of language needed by professionals. This may ultimately necessitate the production of separate patient-facing and GP-facing summaries. Whilst time-consuming, the benefits of this have been explored (Lin et al., Reference Lin2012, Reference Lin2014; Weetman et al., Reference Weetman2021), and in future, the use of generative AI to ‘translate’ technical discharge summaries into patient-friendly language (Kim et al., Reference Kim2024; Zaretsky et al., Reference Zaretsky2024) may significantly reduce the additional workload. However, detail on the delivery of patient-focused discharge communication is beyond the scope of this article, and extensive dedicated research and improvement work continues to be undertaken by other research teams (Becker et al., Reference Becker2021; Spencer and Singh, Reference Spencer and Singh2021; Spencer et al., Reference Spencer, Shariff and Dale2025).

How to understand the recipient generalist paradigm

To further improve interprofessional discharge communication, the emergent question is: how can hospital authors better understand the recipient primary care perspective? We argue this should start with an understanding of the traditionally different approaches of generalism and specialism. There are common misconceptions of generalism, such as GPs operating as ‘guideline machines’(Smith et al., Reference Smith2021) and ‘jacks of all trades’(Reeve, Reference Reeve2023). These are now increasingly dispelled by a recent redefinition of ‘expert medical generalism’: the ability to work with a patient to tailor a management plan to their individual needs as a ‘whole person’, in an interpretive manner (Reeve, Reference Reeve2010, Reference Reeve2023). This involves a different approach to decision-making, where ‘best-fit’ management plans are tailored and account for contextual details, in order to work beyond the limitations of clinical guidelines for individual patients, especially those with complex care needs. This process, also referred to as ‘knowledge work’ (Reilly et al., Reference Reilly2021), contributes significant value to the quality and safety of care provision. It is likely to be highly beneficial for discharge summary authors to appreciate the nature of this approach when trying to understand the purposes a recipient GP will use the content of the summary for, and particularly how they may handle complex care. These concepts are illustrated by the united model of generalism (Reeve and Byng, Reference Reeve and Byng2017) in Figure 3, which was devised to demonstrate how different care needs can require the differing approaches of generalist and specialist care, as well differing levels of multidisciplinary care. It also shows how discharged patients’ needs may cross over from needing standardised care in hospital, to needing interpretive expert generalist care predominantly in the community: a change in the paradigm of care and decision-making, as has been recognised more generally at the primary–secondary care interface (Johnston and Bennett, Reference Johnston and Bennett2019). The model is therefore an ideal start point for discharge summary authors to conceptualise when including greater contextual detail may become of greater value after discharge, when compared to inpatient care.

Figure 3.

The United Model of Generalism (adapted from Reeve and Byng, Reference Reeve and Byng2017), illustrating how the differing needs of patients may benefit from the traditionally different decision-making approaches of generalist and specialist care. Hospital discharge can represent a change to an interpretive decision-making approach, which may require greater contextual information within discharge communication.

Patients receiving standardised specialist care for single problems (quadrant 2), such as a young adult with no past medical history admitted for an elective tonsillectomy, are likely to have little need for expert generalist interpretive care after discharge. There would be no obvious need for additional contextual details to be included, meaning this type of standardised care scenario can benefit maximally from the existing style of information standards. However, patients with ‘uncertain and changing complex care needs, requiring coordination and review’ (quadrant 4) are likely to benefit from expert generalist care after discharge, and a higher level of contextual, narrative, and explanatory detail is likely to be beneficial for GPs to maintain quality and safety. Examples might include details regarding chronic pain medication discussions with the patient, that the GP might later build on in future decisions, or the rationale for anticoagulation decisions in patients with a recent increase in falls risk, that might later evolve. If authors can use this type of framework to tailor the level of detail (Figure 2) to where it is helpful and not a hindrance, the benefits of information standards can be embraced whilst their limitations are simultaneously mitigated. Without this mitigation, the increasing uptake of standardisation being encouraged (The Professional Records Standards Body, 2023) is unlikely to improve discharge communication, particularly for patients whose care relates to quadrants 3 and 4.

Next steps: actions for improvement

We discuss three key opportunities to increase secondary care teams’ understanding of the community-based expert generalist paradigm and to improve discharge communication:

Conclusion: benefits beyond discharge

To further improve, discharge communication and its related policies must evolve beyond the limitations of generic standards and templates. We propose a paradigm shift to purpose-driven summaries, rooted in a change in interprofessional understanding and practice. This can be achieved through the development of improved support for authors, experiential learning, and communities of practice. There will clearly be implementation challenges to overcome, most notably in terms of time and resource, as well as the historic cultural divide between primary and secondary care that these measures seek to bridge. However, any necessary organisational and technological changes, such as to educational pathways and IT software, should benefit cross-interface communication more widely and assist the NHS response to its integration agenda (Department of Health, 2012, 2022), further strengthening the case to pursue this body of work. Progress in this field will also contribute to greater understanding of what is required to work towards Lord Darzi’s proposed ‘left shift’ in patient care (Darzi, Reference Darzi2024) to the community.