How GPs are being buried under secondary care work
Measures taken in 2016 to stop hospitals shifting work onto GPs appear to have made little difference, reports Anviksha Patel
'CCGs refuse to fine secondary care for this. Money talks and it would be the only way to stop this abuse.’
This is the consensus among GPs fed up of hospital colleagues dumping work on them that they should be completing themselves. Faced with workloads that are higher than ever, GPs do not have the capacity to carry out extra tasks created by consultants, they say.
It wasn’t supposed to be like this. Three years ago NHS England brought in new measures, in an attempt to ease the strain on GPs.
In the 2016/17 NHS standard contract, it introduced requirements for NHS trusts to stop the blanket practice of sending patients back to primary care for failing to attend outpatient appointments, as well as requirements to send discharge summaries to GPs within 24 hours and to refrain from sending patients back to their GP to get a referral to another consultant for a related symptom.
What the NHS trust standard contract says
DNAs discharged ‘The contract requires that a provider’s local access policy must not involve blanket administrative policies under which all DNAs are automatically discharged; rather, any decisions to discharge are to be made by providers on the basis of clinical advice about the individual patient’s circumstances.’
Discharge summaries ‘Discharge summaries following inpatient/daycase care and A&E attendance must be issued to general practice within 24 hours.’
Consultant-to-consultant referrals ‘The provisions…enable onward referral by a secondary care clinician where the onward referral is directly related to the condition for which the original GP referral was made or which caused the emergency presentation.’
Yet figures obtained exclusively by Pulse show secondary care workload dumping in all these areas is continuing – with little sign of improvement.
This is still piling pressure on GPs that they can’t handle. Dr Farah Jameel, BMA GP Committee executive team workload lead, says it is ‘unacceptable’ for secondary care to dump work on GPs, which ‘takes up valuable time in which they could be offering appointments to other people’.
This flies in the face of the hospital contract and a collaborative approach to working
Dr Farah Jameel
Dr Jameel says: ‘The BMA’s GP Committee has been clear this flies in the face of the hospital contract and, more broadly, a collaborative approach to working. Missed appointments – for whatever reason – are frustrating for all doctors, but it’s not in patients’ best interests to be shuttled between hospital and GP when this happens.’
The BMA GP Committee has been lobbying the NHS for some time. In 2016, it issued its ‘urgent prescription’ document, which called for the end of ‘inappropriate clinical and bureaucratic workload shift onto GP practices’. NHS England subsequently changed the 2016/17 standard contract to bring in the new measures, including the discharge of DNAs.
However, data collected from 84 trusts by Pulse through a freedom of information request show around 45% of patients who miss their first hospital appointment are being sent back to general practice – hardly any change since the contract requirement was introduced (see graph, below).
These remain blanket policies in some cases. For example, Hillingdon Hospitals NHS Foundation Trust’s policy says ‘any patient who does not attend their agreed routine appointment (new or follow-up) will be discharged back to the care of their GP’.
Similarly, Homerton University Hospital NHS Foundation Trust says ‘the default position will be to discharge patients who do not attend their first appointment’.
These are just two examples of many. Dr Nicholas Grundy, chair of grassroots campaign group GP Survival, says: ‘The discharging after a single DNA is infuriating and happens at least a few times a week.
‘There’s a risk for patients if they are discharged without being seen; I can understand trusts doing this if they miss multiple appointments, but not one.’
Secondary care discharging patients who DNA is a significant issue in terms of rearranging appointments
Dr Henry Stafford
It’s not just a problem in England. Renfrewshire GP Dr Henry Stafford says: ‘Secondary care discharging patients who DNA is a significant issue for us in terms of time spent chasing and rearranging appointments.
‘In the past they were often offered three appointments, now they are usually discharged after a single DNA. I would estimate about half of those patients tell us they either didn’t receive an appointment letter, had an opt-in number to call that no one answered, or even received the letter after the date of the appointment.’
Late discharge summaries are also a problem. According to FOI data supplied to Pulse by 51 trusts, there was a 12% increase between 2015 and 2018 in the number of discharge summaries being sent beyond the 24 hours specified by the contract (see graph, below).
For example, at Tameside and Glossop Integrated Care NHS Foundation Trust it is local policy to send GP summaries for inpatients and the emergency department within 48 hours, and for outpatients within five days. The trust says the majority of its discharge letters are delivered within 24 hours, but it aims for 48 hours because circumstances, such as staff availability, can lead to delays.
Dr Grundy says: ‘Delayed discharges carry risk if actions are on there which don’t get done. The classic is a hospital discharge saying something like “GP please recheck kidney function in 48 hours” – not much use if you get the letter a week later.’
This failure by secondary care has repercussions for patient safety. One GP describes the situation as ‘appalling’, adding: ‘I had a patient who’d been to hospital coughing up blood. He’d been given tranexamic acid, but he had a rash all over, which looked like a drug reaction.
‘We had no discharge letter. I had no idea what was going on. My receptionist had to spend all afternoon trying to get a discharge letter. It took five days, which was appalling. I needed to know what their diagnosis was.’
Trusts seem very fond of copying GPs into results to try and dump risk
Dr Zishan Syed
Similarly, one rural GP says: ‘We get hundreds of requests for blood tests and we simply do not have the staff or appointments to complete all these tasks.
‘We also have no idea how to react to the test results when they hit our inbox, so it’s unsafe.’
Kent GP Dr Zishan Syed says even when correspondence is eventually sent by hospitals, it is often used as an opportunity to foist responsibility for the patient’s care onto GPs.
‘Trusts seem very fond of copying GPs into results to try and dump risk in case they forget to do things,’ he says. ‘In some instances, patients have not been recalled because the hospital has forgotten. It is left for me to re-refer them.’
Manchester GP Dr Siema Iqbal says the increasing complexity of patients only worsens the problem. ‘You can’t skim through a letter – you don’t want to miss anything. I remember eight years ago the admin was nothing like this – now it is more complex, plus there’s more chasing.’
There has been some progress in consultant-to-consultant referrals – which ought to be straightforward – but less than might have been expected.
The 2016/17 contract’s technical guidance explicitly permits consultants to refer patients to specialists in the same trust for a related condition without sending them back to the GP – something they had previously been reluctant to do.
Pulse’s figures, based on data from 59 trusts, show consultant-to-consultant referrals rose by almost 6% between 2015 and 2018. Yet referrals nationally are rising at a similar rate.
North London GP Dr Philippa Vincent says: ‘Consultants continue to inform us they are unable to refer on to another consultant. We send all these letters back and then they do them – but don’t seem to learn for the next time. The frustration is this takes time and effort and sometimes we’re portrayed as obstructive and unkind in declining this work.’
A recent Pulse survey of 813 GPs showed how much pressure this is exerting on GPs. It found that since 2016, a third of GPs have experienced a ‘high’ increase in trusts sending patients back to them after they failed to attend an outpatient appointment.
A further 38% said they’d seen ‘some’ increase. More than half of the GPs in England said they had contacted their CCG about secondary care colleagues offloading work on them, but almost all said no action was taken.
Local GPs should ensure their CCG takes appropriate action in line with the national contract
NHS England spokesperson
Back in 2017, a Pulse investigation revealed that not a single CCG had taken sanctions against hospital trusts for unnecessarily sending patients back to the GP, even though 3,600 formal complaints had been made by practices for this reason.
One north London GP says this lack of action persists: ‘I have had zero response, despite asking for feedback. I was told it would be raised at primary and secondary care meetings. It feels like I've wasted time and effort in feeding back.’
Of course, trusts are feeling the pressure themselves, and the workload dump is often a result of this.
Dr Grundy understands this point: ‘I have some sympathy with the trusts in terms of discharge letters. It’s not their fault that NHS IT is such a disorganised mess that it’s impossible to get an electronic document from one bit to another in anything like good time - that’s a central problem, and despite all the enthusiastic rhetoric of the last few years very little has improved.’
I know the hospitals are stretched but we are sitting like glorified medical secretaries
Dr Janine O’Kane
NHS England says it is up to CCGs to get hospitals into line. A spokesperson says: ‘Good communication and co-operation between primary and secondary care is a vital part of delivering high-quality care. Where there are remaining concerns, local GPs should ensure their CCG – whose governing body they elect – takes appropriate action in line with the national contract.’
But GPs across the UK are facing workload dump in numerous forms. Belfast GP Dr Janine O’Kane says: ‘Patients are directed to us by the hospital to get their results, we are asked to do blood tests, asked to carry out ECGs by psychiatrists before prescribing dementia medication, asked to show patients how to inject clexane – despite the hospital prescribing it – as well as follow up on certain conditions.
‘The usual retort is “you are the only GP who will not do this”. I know the hospitals are stretched but we are sitting like glorified medical secretaries or junior hospital staff doing hospital work.
‘Some still do not get that we have our own work to do and patients to see and treat. We are trying to fight our corner but everyone is stretched to the limit and in some ways we are pitched against each other when we should be working in harmony.’
Until there is a real change in this culture, GPs can expect to be treated as house officers indefinitely.
‘We are drowning in extra work we have to do’
Hospitals say ‘if you’ve got a problem, go and see your GP’, but we’ve already referred the patient to them. What more do they want us to do?
I have a heavily diabetic patient whose kidney function is dropping by the week. I have no idea what to do with someone with an eGFR of nine who is already blind The hospital won’t see him earlier than November. But that is their specialty. We’re left doing blood tests and I’m not sure what else I can do.
What are hospitals doing if they’re not seeing the very sick people? GPs are not specialists. Should we as GPs be sending back inappropriate referrals to hospitals?
We are torn because it’s easier to just do it for them. Writing the letter to have a discussion to say ‘this is really not appropriate’ is too much. Equally, the poor patient is waiting days while we ﬁght over who should be doing what. For the greater good and long-term gain we should be ﬂagging all these things up, but I’m too busy to do that.
That makes it even more difficult. Late discharge letters are also a problem – the main issue being the clinical risk involved.
Not having a discharge letter – or having a discharge letter that doesn’t tell you the drug the patient has been started on, or doesn’t say ‘please continue this drug’ – makes it hard for GPs to ensure treatment is safe. We’re not mind readers.
Dr Brigid Joughin is a GP in Newcastle and Gateshead