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GPs buried under trusts' workload dump

Almost half of patients who miss first hospital appointment are sent back to GP

Exclusive NHS trusts are discharging just under half of patients who do not attend their first appointment back to their GP, with some enforcing this approach as a blanket policy, a Pulse investigation has revealed. 

This is despite contractual requirements introduced by NHS England three years ago designed to stop work being pushed onto GPs, which state trusts must not automatically discharge patients who did not attend (DNA).

GP leaders said it is 'unacceptable' that trusts are creating extra work for GPs by not following up DNA patients themselves and warned this 'takes up valuable time in which [GPs] could be offering appointments to other people’. 

In 2018, 45% of patients who missed their first secondary care appointment were discharged (around 553,000 out of 1.2m), according to data obtained by Pulse from 84 NHS trusts in England through freedom of information (FOI) requests.

This marks virtually no change since 2015 when 47% of DNA patients were discharged upon first appointment (around 538,000 out of 1.1m), according to Pulse's data.

 

Meanwhile, some trusts have policies in place that directly breach contract requirements.

At Hillingdon Hospitals NHS Foundation Trust, it has a policy in places that states ‘any patient who does not attend their agreed routine appointment (new or follow-up) will be discharged back to the care of their GP’.

Homerton University Hospital NHS Foundation Trust says ‘the default position will be to discharge patients who do not attend their first appointment’. 

GPs have said the mounting number of DNA patients discharged back to them is creating problems for general practice across the UK.

Dr Nicholas Grundy, chair of grassroots campaign group GP Survival, said: ‘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.’ 

Renfrewshire GP Dr Henry Stafford said: ‘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.’ 

BMA GP Committee executive team workload lead Dr Farah Jameel said the approach was 'unacceptable'.

She said: 'While we recognise that the whole NHS is under intense pressure, it is not appropriate for hospital management to pass their responsibilities to GPs.

'The BMA’s GP Committee has been clear that this is unacceptable and flies in the face of the hospital contract and, more broadly, a collaborative approach to working.'

She added: 'Missed appointments – for whatever reason – are frustrating for all doctors, but it’s not in a patients’ best interests to be shuttled between hospital and GP when appointments are missed.

An NHS England spokesperson said: ‘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.’ 

Pulse's investigation also revealed the number of discharge summaries being sent by NHS trusts in England to GPs later than the required 24 hours has risen by 12% in the past three years, despite preventative measures being brought in.

 

Readers' comments (18)

  • having had the joy of trying to book an appointment for a relative that was cancelled, re booked, sent 2 appointments on different days and then when we finally sorted out a date to attend arrived to be told we had no appointment and we had missed an appointment that had been cancelled by them previously, they lost the notes and we had to wait 2 hours to be seen. now attend a different trust out of area. this is not an unusual story and I hear it every day from my own patients.

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  • The real problem is those practices that don’t use a template letter to bounce these back.

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  • Nhsfatcat

    Excellent. We can now off list anyone who DNAs and refer them back to... oh!

    More seriously, if we do not act on the notification from the great and the good we would seen to be complicit in the failure of the patient being seen.

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  • Hospital admin - and especially appointments - are absolutely appalling. This leads to lots of confusion and frustration. This needs sorting out. Do this, and many DNAs will no longer happen.
    As for sending them back after one DNA: this is a contractual breach. Two contractual breaches in a GP surgery usually triggers significant contract action. if commissioners would treat it as such - fine them, or downgrade their CQC assessment so that the best they can get is ‘required improvement - then the hospitals would take action. At the moment they just shrug their shoulders and carry on, as they know CCGs won’t do anything.

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  • And then there are the patients who actually ring to say they can't attend on that date and can they rearrange?

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  • DrRubbishBin

    This is a massive issue, millions of GP appointments every day are taken up by patients told to see their GP to get re-referred for something they've already been referred for because the patient missed the appointment or (quite often) the hospital screwed up in some way. A template isn't the answer when they've already wasted an appointment. It's a TOTAL waste of a GP appointment and benefits NOBODY. I guess the only thing it doesn't it help produce a little more turn over in the hospital waiting list where ANY excuse to get a patient off the waiting list is a ruthlessly exploited. It's a policy to benefit the pen pushers - NOBODY else gains

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  • Strange if patients DNA GP they come back to GP
    And if they DNA Hospital, .. many of them come back to GP!!!

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  • Everything comes back to the GP now. Universal problem solver."The GP is best placed....." Not.

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  • Quite often the missed appointment is the fault of the hospital. Appointments never received or the letter arriving late

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  • Our local referral process: see patient - referral decided as appropriate outcome (watching your back for CCG referral reduction targets whilst balancing the risk of clinical negligence and constant reminders that we are failing in early cancer diagnosis) - refer to referral triage - referral triage suggests appointment with chosen speciality - refer for appointment via C&B - referral password generated - patient returns to collect referral password - patient unable to make appointment as 'no appointments available' - patient calls surgery to state no appointments available - encouraged to continue trying - calls local trust multiple times to be offered appointment in many months time (no choice offered) - said appointment cancelled - patient calls again to book another appointment - appointment offered, only patient given incorrect information - patient receives letter saying original appointment missed, so if still wishes to be seen, go back to GP - start at the beginning because target times have been breached. Repeat
    Incident reported to CCG - investigated - many months elapse before any response - standard system excuses trotted out (system changed, new procedures, triage oversight, pro-formas, streamlining DXS procedures bla bla bla) - nothing changes - repeat. Help me somebody ....

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