Optimising post-acute coronary syndrome care: the case for a structured 14-day check

Angad Singh

doi:10.3399/bjgp26X743865

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The case for a structured 14-day check
David Bossano

Published on: 05 January 2026

Published on: (5 January 2026)
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The case for a structured 14-day check
David Bossano, GP, St Leonards Practice, Exeter
I am often involved in discussions with primary- and secondary-care colleagues, about where the demarcation best lies between ongoing care/chronic disease management/continuity of care and management of acute episode (admission) as we debate how best to respond to discharges asking GPs to follow up renal function, request x-ray, refer on, etc., etc.

My rule of thumb is that medical needs within 2 weeks and possibly up to 4 weeks of the acute admission/episode are best considered part of the acute episode of care. This for clinical and logistical reasons.

Clinical reasons are that the acute (hospital) team should have greater awareness of the events immediately prior to discharge, are better placed to observe trends (eg CRP falling compared to during admission), are more familiar with the complications and immediate risks following the admission and (hopefully) have a vested interest in correcting any issues arising as a result of the admission e.g. immediate medication side-effects, prescription and dispensing errors etc.

The logistical issues are that discharge letters may take more than 2 weeks to be sent, received, processed and actioned, and that availability for a GP or practice nurse review may take a further 2 weeks or more.

As such I would suggest that secondary care should set up a post-discharge service (not just for acute coronary syndrome but ideally for all medical discharges), whereby a member of the secondary care team contact...
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I am often involved in discussions with primary- and secondary-care colleagues, about where the demarcation best lies between ongoing care/chronic disease management/continuity of care and management of acute episode (admission) as we debate how best to respond to discharges asking GPs to follow up renal function, request x-ray, refer on, etc., etc.

My rule of thumb is that medical needs within 2 weeks and possibly up to 4 weeks of the acute admission/episode are best considered part of the acute episode of care. This for clinical and logistical reasons.

Clinical reasons are that the acute (hospital) team should have greater awareness of the events immediately prior to discharge, are better placed to observe trends (eg CRP falling compared to during admission), are more familiar with the complications and immediate risks following the admission and (hopefully) have a vested interest in correcting any issues arising as a result of the admission e.g. immediate medication side-effects, prescription and dispensing errors etc.

The logistical issues are that discharge letters may take more than 2 weeks to be sent, received, processed and actioned, and that availability for a GP or practice nurse review may take a further 2 weeks or more.

As such I would suggest that secondary care should set up a post-discharge service (not just for acute coronary syndrome but ideally for all medical discharges), whereby a member of the secondary care team contacts the patient 2 weeks post-discharge and checks they have no relevant new or ongoing clinical issues related to the admission, they have a months supply (from discharge) of any changed medicines, they have a sick note if required and any follow-up tests and referrals etc suggested by secondary care are in hand.

Depending on the clinical scenario, practice follow-up might be better scheduled for 4-6 weeks after discharge if appropriate or at the next QOF/chronic disease review, thus providing the relevant long-term continuity and follow-up. Continuity of care is best for patients, and I believe we should aim for continuity within each acute clinical episode as well as relational continuity between the GP, practice and patient over many episodes/events.
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Competing Interests: None declared.