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At the heart of general practice since 1960

Helping a patient who has waited too long

The number one complaint about the NHS is the length of time people have to wait for investigations and treatment. But this situation has not arisen overnight, and its effects are not uniform throughout the country. Factors include:

 · Increased referral rates due to advances in medical treatment, consumer demand, greater morbidity in an ageing population and, increasingly, fear of litigation

 · Under-investment in high-tech equipment (which also dates quickly)

 · Shortage of trained staff

 · Bed closures that have left no slack in the system; even minor glitches have a knock-on effect

 · Waiting list initiatives that favour quick procedures ahead of complex problems1

 · Lack of residential and nursing home places so that elderly patients cannot be discharged

 · The delay: appointments are wasted as patients get better/move/forget

 · Inefficient appointment systems.

What are the consequences for GPs?

Patients who cannot get satisfaction from secondary services turn to their GPs for help, and are often encouraged to do so by overburdened hospital staff.

The two-week referral rule for suspected cancers has led to increased waits for other serious and/or debilitating problems.2 3 4

The result is that patients often consult several times for the same problem (a waste of their time, as well as the practice's) and GPs have to write additional letters or provide expensive stop-gap medication.

What are a GP's legal responsibilities?

The GMS contract states that GPs must provide all necessary medical services. This includes timely and appropriate referral, and is reinforced by the GMC's Duties of a Doctor. Failure to expedite a needy patient through waiting list barriers could cause harm and/or generate a complaint.

A GP's prime responsibility is to the individual patient, whereas hospital consultants have to juggle the apparent medical needs of all those referred to them. This raises ethical questions about equity of access, as GPs are forced to compete against each other to get their patients seen earlier.

What can you do for Mr King?

A plea for fast treatment may be based on pain, fear of serious or deteriorating disease, work/domestic responsibilities or an imminent holiday; or it may be seen as a right by some taxpayers.

GPs must distinguish between clinical urgency and patient demand. Impassioned complaints can sometimes make this difficult, and discussion with a colleague or the consultant may help. If you think there are good clinical reasons why the wait is unsafe, you can telephone, fax or write to the consultant to make your case. Keep a record of your actions. But if fast-tracking is not clinically justified, it is your unpleasant duty to explain this. You may want to compromise by agreeing to relay the patient's concerns to the consultant (while warning that it is unlikely to do much good). This really is a waste of both doctors' time.

What other options does Mr King have?

Sometimes direct access to investigations can unlock a problem, or the practice may be able to perform, say, ECGs or sigmoidoscopies itself. However, resources are rarely switched from secondary care to pay for GPs' time and equipment.

Mr King may ask you for referral to another hospital. The PCO may not agree to this if it would be more costly than using services that have already been commissioned. He may also be willing to pay for private treatment. If he wishes to make a formal complaint, he should be told to contact the hospital directly, as you have fulfilled your obligations.

You can also suggest contacting the local MP ­ after all, politicians, not doctors, decide the level of NHS resources.

Mr King is in a storming rage as he's been told he must wait three months for a scan. The consultant's secretary has told him to see his GP if he's unhappy. Why are hospital waits so long? Dr Melanie Wynne-Jones examines.

Key points

 · Waiting times generate extra work for GPs

 · Referral guidelines help to determine which patients warrant urgent investigation and treatment

 · Access and practice-based services can relieve pressure on waiting times

 · Contact the consultant personally if really worried about a patient

 · Record your attempts to expedite patients' treatment

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