Elizabeth is a freelance medical journalist specialising in public and occupational health. She is also a communication coach. Her website, www.lonelyfurrowcompany.com, features further information about communication issues
At a GP surgery in rural southwest UK, an elderly husband was picking up a repeat prescription for his wife. In front of a full waiting room, the receptionist asked what was wrong with her.
Attempting discretion, in confidential tones the man described his wife's symptoms but a glass barrier prevented the receptionist from hearing him. Embarrassed, he raised his voice to repeat the information. Looking at the prescription, the receptionist – a former caterer – said: "She shouldn't be taking two of those a day!"
Now anxious, the man replied that the GP had been prescribing that dose for years. The receptionist backed down. No apology was made.
This perhaps not uncommon incident illustrates the importance of communication skills in general practice. Good communication can sometimes be a casualty in a busy surgery environment, but seemingly small details can have a significant effect on the patient's experience.
As Sarah Rhodes, practice manager at the Bradford-based Avicenna Medical Practice and winner of the Management in Practice HR and Training Award 2009, says: "Poor communication can have a massive impact in general practice. Patients can be misunderstood or not communicated to effectively, leaving them upset, angry and unsure. This then causes complaints and a breakdown in the surgery-patient relationship."
So how can similar communication failures be prevented? To go back to the example we started with, the practice manager's cramped office was located in the basement and he could have no overview of what was going on at reception. But in most GP surgeries, the practice manager would take onboard this responsibility.
Ms Rhodes – responsible for a city practice with 6,200 patients cared for by a team of six GPs, two healthcare assistants, two practice nurses, six receptionists, one senior receptionist, two read coders, one summariser, one secretary, two administrators and herself – explains:
"Staff and patients tend to listen to the practice manager. If a practice manager has good communication skills, this rubs off on the rest of the staff. Patients also find it reassuring having someone to speak to who understands them, can articulate their feelings and respond."
On a daily basis, the practice manager has to deal with a team of secretaries, receptionists and records staff and clinicians, as well as external contacts from the primary care trust (PCT), local hospitals and social services.
Moreover, as additional responsibilities are added annually to the practice manager's brief, the role – already central to the daily running of the practice – has become crucial to the meeting of the practice's health targets.
But as Ms Rhodes points out: "If a practice manager lacks good communication skills, this causes problems due to lack of clear instruction, feedback and constant information sourcing.
"Poor communication can have a negative impact on tasks and work allocated to staff. Instructions need to be communicated clearly so that staff understand what is being asked and expected of them. If they don't understand, this can cause low morale, stress and a workforce that is less effective and efficient."
Regarding her own practice, Ms Rhodes comments: "Communication is paramount. We have done training sessions on communication and communication breakdowns – so staff can see where things can go wrong. Staff need to be articulate and clear about what they are trying to achieve and how they can best assist a patient."
Benefits and barriers
Practice managers recognise the need for enhanced communication skills at every level of their team. They acknowledge the benefits to the practice, which include:
In a patient-centred NHS, patients benefit too. However, in modern general medical practice, the following barriers to good communication are all too familiar:
Stress and fatigue
On its Connexions Direct careers database, the government suggests that a working week of 37 hours is the norm for practice managers, with the ad hoc exception of longer hours when required.(1) But one practice manager in a large London practice has said she regularly works a 55-hour week. Stress and fatigue for both clinical and administrative staff have become commonplace.
The working environment may also bring its own stressors. The surgery and waiting areas may be noisy or uncomfortable; too hot, cold or stuffy for staff – both clinical and administrative – to concentrate on what is being said.
Similarly, under pressure to manage an unrealistic workload, staff may forget that patients are ill and possibly frightened. What appears as aggressive patient behaviour, characteristic or not, may alienate staff and their reactions may be counter-productive and equally aggressive.
Personal communication style can be misinterpreted. Even though she apparently meant well, the receptionist in the southwest surgery had a brusque style, making her appear unfriendly. She was also unaware how her personal communication style impacted on others.
On the other hand, patients may be soft-spoken, non-assertive and understate their concerns. Expressing concerns by quoting a third party – eg, husband, parent – is a common strategy that may obscure, rather than communicate, the realities of the situation. Staff need to understand this.
Successful team performance also depends on the quality of communication skills displayed by the organisation's leaders. Depending on education and inclination, the standard may vary.
The General Medical Council (GMC), for example, has reported complaints against doctors referring to the "harsh, even arrogant tone" of some letters received by patients.(2) But when challenged on this, it appears, doctors are genuinely surprised by patients' reactions.
And, although generally regarded as well prepared for complex communication tasks – such as breaking bad news or dealing with angry or distressed relatives – even GPs may at times fail to perform well.
A top-down tendency to prejudice, for example, may at times be endemic in the culture of any NHS organisation, expressing itself through poorly chosen language.
In October 2006, for example, in the Journal of the Royal Society of Medicine, the UK's leading patient advocate Harry Cayton criticised some of the language used in the health service. Arguing that responsibility towards patients also includes courtesy, Mr Cayton warned: "Language reflects and shapes our thinking and therefore our behaviours."(3)
He cited negative language associated with older patients and customers: "The use of the term 'frequent flyer' … to describe elderly patients regularly entering hospital is demeaning. It trivialises a patient's condition and implies they are enjoying being in hospital as though it were a trip or holiday. And people with Alzheimer's disease are simply reduced to a 'dement'."
In general practice, clinicians may also miss a shift in a patient's condition if they are not listening with due attention – the "I've heard it all before" syndrome.
As Ms Rhodes explains: "GPs don't tend to be good communicators. They know what they want but cannot always explain this in a way that will be understood by all. This can cause problems for the practice manager as they have to act as a go-between, finding out what the patient wants and then going back to staff and explaining this in a fashion that can be grasped and taken in."
The situation is not without remedy. Communication skills – reading, writing, listening, speaking, building rapport and creating empathy – can be taught.
But the first stage, as ever, is to recognise the problem. And practice managers – currently numbering 8,000 in the UK – are responsible for persuading staff members that poor communication skills undermine team performance and that the quality of staff communication skills may need cranking up. Listening skills are a classic example of this. They are crucial to good communication but very little practised.
However, while practice managers might identify endemic communication training needs, this training may be difficult to put in place. Available resources could be scant.
For example, given that many practices have to be open for patients from 8am–6.30pm, finding time to release staff for communication training can be something of a headache.
Some practices, such as the Avicenna practice, use lunchtimes for group training. But for small rural practices totally reliant on a clutch of part-timers at every level, this may not be possible. As one practice manager has said: "There is no downtime in the schedules. So we have to try to get everyone together out of hours once a month."
Now that drug companies are no longer allowed to sponsor training events and pay for staff time, practice managers also have a budgeting problem of paying for the training. Of course, the huge variation in the sizes of GP surgeries means there is no one-size-fits-all training package to solve these communication issues.
Depending on available resources, for example, practice managers may elect individual coaching, group sessions or interactive workshops involving the whole team.
"What is most effective depends on what you are training for," said Ms Rhodes. "I tend to do group sessions with the offer of a one-to-one follow-up if needed later. I also back up all my training with step-by-step guides for staff and instructions to patients, so they have a resource to return to in order to jog their memories."
An effective communication strategy helps. You can, says Ms Rhodes, evaluate this by setting up systems to record patient complaints – there should be fewer. Staff will be able to produce "good-quality work in a timely manner that shows they have understood their instructions."
At the Avicenna practice, a blend of techniques for communication and dissemination of information works well. Ms Rhodes explains: "Confidential information is passed on between clinicians via patient records. Other instructions are delivered word-of-mouth first and followed up by email or on paper. For patients, we use posters, newsletters and letters to communicate changes within the practice.
"But I feel the most effective way is always the face-to-face personal touch followed up by an email or paper memo. This gives the staff member – or the patient – the chance to listen, speak, ask questions and make sure they understand what you are saying/asking. The written format backs this up with something concrete to look back on as a resource for the future."
Since practices differ, here is a checklist drawn up by practice managers for practice managers. Consider these issues:
1. See http://www.connexions-direct.com/jobs4u/index.cfm?pid=51&catalogueConten...
2. Downie R. "Writing, education and therapy: literature in the training of clinicians". In:
Sampson F (ed). Creative Writing In Health
And Social Care. London: Jessica Kingsley
3. See http://www.networks.nhs.uk/networks/page/545