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A faulty production line

GP 'black alert' guidance suggests cap of 25-35 routine consultations a day

GP practices facing an unsustainable workload should divert or cancel all routine appointments, under a new 'black alert' system proposed by the BMA.

The BMA, which voted in favour of GP practice black alerts last year, has established four 'operational pressures escalation levels' similar to the system used in hospitals.

Whether a practice can take the action unilaterally, without prior approval, is currently unclear.

The BMA guidance, prepared by the GP Committee, suggests that 25 routine appointments a day are a 'safe' limit for individual GPs, with 35 deemed as 'unsafe'. For more complex consultations, the number is lower.

After this, the practice should 'divert patients to other clinicians or alternative providers or later sessions/days'.

If all GPs in a practice are working at unsafe levels, a locality hub should take on its 'overspill' patients.

Meanwhile, if all practices in the same locality are reporting unsafe working levels, all routine long-term conditions clinics should be cancelled, and hospitals told 'discharge management will be suspended until primary care recovers'.

This comes as a Pulse survey revealed that GPs in the UK have an average of 41.5 patient contacts every day - 60% more than the number considered safe by European GPs.

The guidance says that 'appropriate limits on workload will depend on the unique circumstances of each practice and the preferences of each individual GP, as well as the complexity of care being provided'.

The BMA suggests therefore 'a range in the number of appointments per day to show when a GP may move into more "unsafe" practice (red), depending on whether the appointments are routine or complex'.

The guidance says: 'For example, up to 25 routine doctor-patient contacts a day could be deemed ‘safe’, with GPs only reaching "unsafe" working levels at 35 or more routine patient contacts per day.

'In comparison, anything over 15 doctor-patient contacts for long-term, complex or mental health conditions could be said to be "unsafe" due to the more demanding nature of the consultations.'

The BMA said that the system 'will only succeed within a locality where a range of safe working levels has been discussed and agreed, and where practices are assured that all other providers are operating above agreed minimum quality and capacity measures'.

It added that 'such a system will need peer-controlled audit and free exchange of information'.

GPC chair Dr Richard Vautrey said the guidance meant 'working within the existing contractual mechanisms to be able to deliver a safe and sustainable service'.

He said: 'It's in everybody's interest whether that's the local CCG, NHS England or general practice, to have a sustainable safe service. We would hope that local commissioners will work with practices to enable that to happen...

'No right-minded thinking person would want their patients to be seen by tired, exhausted doctors.'

Dr Vautrey said the black alert system was necessary as GP workloads 'increasingly unmanageable' owing to 'the demand of more complex patient needs, widespread recruitment and retention issues, and years of underinvestment – all of which takes a toll on GPs’ physical, mental and social health'.

The proposal of capping appointments and diverting to overflow hubs formed part of the GPC's Urgent Prescription for General Practice published two years ago, and the BMA's Annual Representative Meeting voted in favour of GP black alerts last June.

An NHS England spokesperson said: 'While arbitrary caps on patient appointments would breach GPs’ contracts, we understand the pressures general practice is facing. That’s why the NHS is investing £2.4 bn extra in GP services, growing the number of new doctors entering general practice, and rolling out evening and weekend appointments to patients across England over this coming year.'

The operational pressures escalation levels’ (OPEL) alert system

Level 1

Individual GPs or other clinicians are at or above the locally agreed safe level of working.

Action: Internal practice action to divert patients to other clinicians or alternative providers or later sessions/days. Notify position to Locality Hub.

Level 2

One practice reaches unsafe working levels.

Action: Practice reports status to Locality Hub. Hub initiates improved triage and allows practice access to booked overspill appointments.

Level 3

Several locality practices reach unsafe working levels

Action: Hub initiates improved or centralised triage and releases all overspill appointments. Other practices and Hub clinics are alerted to potential “Black Alert” status.

Level 4

All practices in the locality report unsafe working.

Action: Locality Hub switches available workforce to address overspill (Triaged and booked appointments) thereby cancelling routine LTC and specialist clinics. Locality alerts Hospital that discharge management will be suspended until primary care recovers. Planned early discharges are therefore temporarily stopped.

Source: BMA






Readers' comments (29)

  • No Hub locally in rural Lincolnshire seeing many more than this daily.Always on black alert or should I say brown alert.

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  • So if 25 patients a day will be the new maximum and currently the average is 41.5. So 16.5 patients per GP per day will be seen in a hub! This will require 39.8% more GPs to work in hubs. Where are they coming from and where is the extra 39.8% of funds?

    This ain’t going to happen. Dream on..

    Perhaps GPs will get a 39.8% reduction in income.

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    its a case of defining safe workloads for the amount of pay... of course the workload is much more... a line has to be drawn in the sand
    and if more is required above this safe level then more funding is required
    stop being the martyrs slowly worked to death
    embrace safe levels for the given pay

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    4 patients per hour
    bring all in at 10 min intervals at the start
    some will be quick some slow
    use the remainder for the days admin duties
    True emergencies can be fixed in as necessary
    3 HOURS 12 Patients

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  • Don’t appear to be at real coal face. 31 face to face 21 telephone advice or notes review following OOH attendance.

    Only 2 admissions though, so either I’m crap at assessment or just on the ragged edge.

    This is going to implode and will end in tears for all concerned.

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  • All GPs have been working way beyond this for years, what about phone calls etc as well as the face to face consultations. Hospital clinics are capped but much easier to do as all prebooked. Very hard to control this other than reporting your practice unsafe and even then there are not enough doctors in the Country to take up the slack.Worldwide problem not just UK

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  • Nobody stops GP partners servicing demand how they want now. If we are asking for 40% of our average daily numbers to go elsewhere it won't be long before they have to take away the money to pay for that which will threaten the viability of most practices. Not sure this has been thought through adequately.

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  • sounds very sensible, bring it on and I MAY go back to BMA membership. What happens to patients after my 25-30 would not be my responsibility. Anyway with recent episode of GP getting a slap on wrist for not seeing acute asthma, we are better off not seeing too many anyway.

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  • Different patients need varying amounts of time. Most GPs would accept some days being longer than others because of this variation , but the fact is that somehow our day is now 11-12 hours every day , and we are continually rushing, working too fast and not having time to reflect. The simple answer is we need about twices as many doctors.

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  • It’ll all be solved by Working at Scale, primary care being taken over by hospitals and tighter regulation of the hopelessly slack cottage industry that is general practice.
    Nothing to do with the simple fact of the exodus of GPs in their mid 50’s

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  • Nice words but nothing will change, it will only get worse which is exactly what I felt when the gp forward view etc was announced

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  • Took Early Retirement

    Too late! Learned today that a former partner of mine has handed in her notice aged 56. No surprise there. I went at 57. It's all just too much.

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  • The current Contract does not allow the luxury of defined number of consultations per year.
    Until the Contract is changed to appointments/ year or we define safety first, we GPs cannot unilaterally say we are going to breach Contracts.
    The Contract will then stop being fee/ patient to fee/ appointment or a salaried Contract with safe appointment numbers.
    But Dr BG' case shows that until BMA begins to define safe working practice, we will be individually responsible no matter how hard we work.
    In Dr BG's case, the poor doctor was covering 3/4 other doctors and not deemed to be doing enough in a timely manner by the expert doctor witnesses. We leave ourselves wide open to Litigation.
    It is upto Richard Vautery and GPC to define safety first. It cannot be an arbitrary practice based concept

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  • I am not sure what the plan here is:

    If we have 10 partners, seeing 30 patients each, we can each divert 5, to make things safer, fine so far.
    But 5 partners are retiring. I might do a half measure recruitment, so only recruit 1 new partner.

    Does that mean I know divert 100 extra patients each day and instead picket a much bigger partnership share? Doesn’t really sit right.

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  • I am concerned "up to 25 routine doctor-patient contacts a day could be deemed ‘safe’, with GPs only reaching "unsafe" working levels at 35 or more routine patient contacts per day". The key word here is "routine". There does not seem to be any limit to unscheduled appointments, telephone calls, additional visits etc. This seems to therefore condone the status quo.

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  • I'm sorry I could not find an adequate reference from a respected journal. So Wikipedia it is;

    Cloud cuckoo land is a state of absurdly, over-optimistic fantasy or an unrealistically idealistic state where everything is perfect. Someone who is said to "live in cloud cuckoo land" is a person who thinks that things that are completely impossible might happen, rather than understanding how things really are.

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  • Which is it? 25 or 35? This will just be another stick to beat us with to reduce pay so all GPs will currently ‘opt-out’ and continue to overwork themselves. I can never see this government agreed to reduce our workload by 40% and expect them to increase pay in line with similar professionals.

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  • All you can eat buffet funding has to go.
    Awaiting the annual stats return on unsafe consulting levels. No partners will report ‘breaches’ as their contract will be hit.
    If the 36th patient is an asthmatics who dies because you don’t see them go to jail. If you don’t follow up someone dumped from hospital with ‘gp to follow up renal failure/dodgy cxr etc’ and they die go to jail.

    Thus the only answer is to take half the profits and work ‘safe’ levels ensuring medicine is best done as a part time hobby for spouses of bankers or landed rentiers

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  • If you (and you should) consider a telephone call, reports, blood results, meds management just as relevant and real as a face-to-face appointment I suspect we are all working 'unsafely' every day. But if we all reduce massively our work to 'safe levels' what is going to happen to the unfinished work (maybe the powers that be genuinely believe we don't do anything - just like when they believed we did nothing at night and none of us would get near QoF targets again due to doing very little work and our general uselessness.
    Do they actually have any idea how much work we are doing 7 days per week?!!

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  • I dunno. I see the potential pitfalls if diverting is going to hit income, but surely starting to define safe workload is a step in the right direction? I like the idea of headlines stating that “80% of GP practices are on black alert”, maybe then the state of primary care will finally get some proper attention?

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  • I welcome this. Society cannot have it both ways. If we are to be locked up for error or even no error then we must have time to think about what we are doing.

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  • I agree with the prior comments, seeing 25 patients a day can affect safety of managing all the clinical workloads in any prolonged tiring full working day. We have experienced that operating patients telephone triage system can reduce the numbers of f2f consultations freeing up some time for Meds Management, Path Links results, checking Docmans/OOH letters etc. But duty doctor days managing influx of multiple emergencies / urgent medications requests etc inevitably causes late surgery nights. Overall doctors stress levels are significantly reduced on normal clinic days. It is one system that is trying to address GP appointments crisis in our area. (North Merseyside)

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  • 25 sounds about right if you have paperwork as well. Does this include vists?
    35 is defo too many if have visits and paperwork too. It's a bit vague though

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  • My comments hold less sway as I speak from the position of having stepped out of general practice a few years ago but relevant as I had literally sat on the precipice several times... but on reflection though workload was an issue it was complexity that was the "demon"

    Whatever changes are made following the BMAs proposal they must establish a system that supports Primary Care to return to a place where compassion, hope, care and support is paramount - where these elements are in place for Primary Care itself.
    NO system should be established that simply makes the situation worse with increased exposure to litigation risk, a widening rift between doctor and patient and a worsening of the well-being of the workforce AND increased complexity...

    IT might be that these proposed measures are the single greatest changes that could be put in place for general practice for a decade or more but then something else might have to give and a suggestion would be to put QoF on hold for a period of 3- 5 years while new patterns of working are established - in parallel a new more meaningful framework could be developed ready for release in 2023...

    BUT the saviour of general practice may simply be to simplify...
    Patients, their needs and the lives they bring have become more complex so the solution is never to make the framework to deliver care more complex - it needs simplification and flexibility with a freer autonomy. General practice was always designed to deal with complexity but not to be hampered by additional complexity.

    Clearly if you simplify payment and quality systems some in the public, commmissioners, contract holders and government will suspect that primary care will "gameplay" and cheat the system but I believe history shows that there is more gameplaying within complex systems as people try to survive ... Primary Care wants to do the right thing for the population it serves why then voluntarily do GPs see more than an average of 40 patients a day... When they could have said no a long time ago?

    So as confusing a response as this is it would be interesting to hear what others think..

    Please ALL do take care - your lives are vital to you, your families, your friends and colleagues and those you serve... There is always hope and always reach out to those colleagues who you see suffering..


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  • This will never happen but the principle might act as a mitigating factor in any brushes with the GMC if they radically re-orientate themselves.
    As for the BMA - well they keep trying to draw lines in the sand but its all a bit retreat from Moscow.

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  • Vinci Ho

    I see this at a slightly different angle : politicians like to draw arguments and rhetorics from numbers , figures . Clearly , my 'beloved' health secretary was one of them.
    For those of us who have been around long enough(I lived through life when GP appointment was 5 minutes each) , this number appears to be a bit of Neverland and the whole 'scheme' not being thought through . But one has to understand the game of politics. It is all about narratives . In fact , the 'right' kind of narrative at the 'right' moment for political bargaining(s).
    Using the word 'safe' or 'unsafe' is a kind of ammunition against this lame duck government with a 'wannabe egalitarian' prime minister but just about managed (JAM) to breathe within a pool of far-right 'elites' fraught with 19th century imperialism. ''An 'unsafe' general practice and hence, NHS , under an elected Tory government ''is a similar argument to ''voting Brexit for a poorer Britain''.
    So , whether is 25 , 30 or 35 as the upper limit of appointments per day , this is a 'weapon' to use considering that it is only a fine line between negotiation and extortion. So spin it !

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  • Another poorly thought out plan that is bound to fail. What is needed is more funding for general practice and not fruitlessly pushing patients around.

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  • I think this is a great idea just to raise awareness more than any practical use - bombard hospital consultants with ‘GP is on black alert’ emails daily and they might think twice about the reflex ‘get the GP to do it’ mentality.....

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  • it won't take too long for NHS England to realise that those working in the hubs are the Drs not in their practices any longer. Next will be the recognition that nurse and paramedics can do hab work for about a third of the price which will leek to the media. Next will be CCG mergers, STP and ACO. Then the end of independent primary care, which some Drs will perhaps welcome
    Is the bma taking NHS England's bait hook line and sinker?

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