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Gold, incentives and meh

How can practices fight unfunded transfer of work?

Dr Gaurav Gupta

Background to the changes

Following pressure from the BMA’s GP Committee concerning the need to address unfair shift of workload from secondary to primary care, a number of further changes were made to the NHS standard contract [which applies to all trusts] in January 2018.

These changes covered new requirements for hospitals, concerning things like issuing fit notes, responding to patient queries, making direct onward referrals and prescribing sufficient. They also covered shared-care arrangements and introduced new deadlines for clinic letters to be sent to GPs.

It is important to note that these conditions apply to all NHS providers like mental health trusts and community trusts – not just acute hospital trusts.

What progress has been made?

LMCs across the country have been working with CCGs and other providers to facilitate the implementation of this contract.

Trusts that don’t comply are in breach of contract so CCGs must act

Our LMC in Kent, for example, has published patient leafl ets and posters, which are being shared with local trusts to increase awareness among both patients and clinicians.

However, we know implementation of the NHS contract has been patchy.

It remains poor in some CCGs, while others have attempted to agree local variations. This causes understandable frustration for GPs and their teams, and it is something the BMA is eager to address. 

How can GPs deal with hospitals that aren’t complying?

These changes are not optional – they are contractual requirements – so if providers are not complying, they are in breach of their contract, and CCGs must hold them to account. CCGs have the ability to act on such breaches by taking remedial action that could include financial sanctions.

However, practices are also key to ensuring these rules are abided by, and it is vital that GPs and their teams push back on inappropriate demands by reporting breaches to the CCG and provider, rather than allow them to continue unchallenged.

Last year, the BMA produced a number of practice template letters that can be adapted by practices for uploading to clinical systems, so that

GPs can easily report breaches to CCGs and providers.

We have also written to LMCs with template letters they can send to their local CCG and hospitals, requiring them to detail how they will ensure these contract rules are implemented.

We would encourage GPs who are experiencing inappropriate workload shifts to contact their LMCs who can escalate the matter on their behalf.

CCGs need to ensure that patients are getting appropriate care from all parts of the NHS and are not being passed inappropriately from secondary care to practices.

These changes are all about good patient care and CCGs should act decisively to implement the NHS standard contract.

Dr Gaurav Gupta is a GP in Kent, chair of Kent LMC and a member of the GPC UK

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Readers' comments (8)

  • I acted on the template letters time after time, I ensured the rest of the practice team had access to these templates, I contacted my local LMC repeatedly. It took a lot of effort and time in addition to the day to day relentless demands. All that happened was an increasing frustration on my part, at a system that didn't respond to my efforts, nothing changed and other workload factors worsened. In one fell swoop I cleared my frustrations. left my partnership and voted with my feet. Best decision I made.

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  • Dr G, I'm sure you are a hardworking and well-meaning chap, but sending these templates back has become pointless. I've been sending at least one a week for the past couple of years and nothing changes. Don't take my word for it, look at the figures, NOTHING HAS CHANGED.

    'Get a sick note from your GP'
    'We don't have any medical input to the [chemotherapy] ward, get a prescription from your GP'
    'GP to refer to specialist'
    'GP to chase results of tests', no longer even a please, just an instruction
    'missed the appointment [that hospital cancelled] go back to your GP and get referred again'
    unhappy with the wait for appointment 'go to your GP and ask him to write to us to expedite'

    I'm sure you know all these and many more. GP is the dog of every specialist nurse, radiologist, physiotherapist, speech therapist, podaitrist, consultant, doctor-in-training, medical secretary, bus-pass-issuer, optician etc

    RCGP, BMA and all their LMC's, Federations, CCG's, locality groups, PCN's, none of you have made any difference. Don't keep telling us to send in the templates, it is the very definition of insanity to keep doing something that doesn't work

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  • I’ve been fighting since May with the local hospital to internally refer someone for the problem caused by them. My first quality alert led to agreement patient would be seen. Unfortunately referral still hasn’t been done despite 2nd quality alert so I’ve had to refer. No one cares about these unsafe work dumps to GPs.

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  • Real financial penalties are the only way to create change.

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  • Stick this into the next hospital contract: every contract breach should mean a £50 fine, every penny of which should go into a pot to be distributed amongst local practices to pay for the work that has been incorrectly pushed out into general practice.
    Then watch the breaches drop 96% in 6 months.

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  • when hopsitals and CCGs do nothing about this it drives GPs out of general practice. So either they preempt the issue and set boundaries of workload with payment, if we are expected to do hospital work, or the hospitals are fined. Its in no ones interest to continue as it is. Once all the GP practices have collapsed and its all noctors and short term and locum contracts there will be no one for the hospital to dump on any more and it will all come back to them big time. This is not how to run a service and it will backfire badly on the dumpers. general practice is currently keeping hospitals functioning for free. it is not a sustainable model for the long term. Hospitals destroy general practice at their own peril. they have been warned.

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  • HW

    Thanks Dr G. But having been 'pushing back' - really hard- for the past 3years and sending these standard letters back time and time again, I concur with the writers of the first two comments. There has certainly been no decline in frequency of these breaches. The only notable outcome has been one of further escalating my workload and that of our admin staff. It has increased, not reduced, my frustrations. My secretaries now have a 3-4 week delay to typing routine referrals why we are paying them to do hospital admin work for a much of their working week. It's not only GPs that are been driven out, our secretarial and admin staff are pulling their hair out too.

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  • I agree with the comments above too from our experience. Sending these letters achieves nothing. Consultants are no longer available to speak to.
    Patients are given excessive expectations of what we can do.
    Hospital colleagues have no respect for GPs and their staff! Many of them will admit they haven't a clue how to do their job properly. Whatever happened to hospital staff having appraisals like gPs do??

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