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The waiting game

GPs to be protected from secondary care workload dump

NHS England has outlined changes to hospitals' contractual terms designed to prevent trusts from dumping workload on GP practices.

In the letter sent today, hospitals are told to implement six new requirements - including a ban on blanket policies for discharging patients back to their GP if they fail to attend an outpatient appointment - 'in a robust and timely way'.

The new rules, first outlined with the General Practice Forward View in April, are being added to the 2016/17 NHS Standard Contract for hospitals.

The GPC had asked for NHS England to review secondary care workload dump as part of its 'Urgent Prescription for General Practice'. 

Under the rules, hospitals will have to electronically send discharge summaries to a patient’s GP within 24 hours for inpatient, day patient or A&E attendances, and within 14 days for outpatient attendances - set to be tightened to 24 hours by 2017/18.

The changes explicitly allow secondary care doctors to onward refer within the same organisation, to cut out the need to refer back to the GP.

It also requires hospital staff to supply patients with medication following discharge for at least a week rather than batting back this responsibility to the patient's GP practice.

The changes mean that hospitals must now notify patients of the results of clinical investigations and treatments.

In the letter, NHS England points out that 'ensuring that people are able to access GP services in a timely manner will also help relieve some of the pressures on hospitals'.

The letter, signed by NHS England's new national director of operations and information Matthew Swindells and deputy chief exeucutive of NHS Improvement Robert Alexander, said: 'Time taken in setting up and rearranging hospital appointments, as well as chasing up delays in discharge letters and details of changes in medication accounted for 4.5% of GP appointments that could have potentially been avoided.'

This amounted to 'around 13.5 million appointments a year', it added. 

The letter said: 'Freeing up this time will enable GPs the ability to see patients more quickly, thereby reducing the likelihood of A&E attendances and emergency admissions. Closer working relationships, with greater communication and sharing of information between GPs and consultants, and their respective teams, were identified as being crucial to reducing workload on both sides.

'The new requirements... were introduced to enable exactly this. It is important that they are fully implemented in a robust and timely way and we urge you to do this.'

Six new requirements in NHS Standard Contract for hospitals in relation to hospital/general practice interface

  1. Local access policies Hospitals cannot adopt blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for rereferral. Hospitals must publish local access policies and demonstrate evidence of having taken account of GP feedback when considering service development and redesign.
  2. Discharge summaries Hospitals are required to send discharge summaries by direct electronic or email transmission for inpatient, day case or A&E care within 24 hours, with local standards being set for discharge summaries from other settings. Discharge summaries from inpatient or day case care must also use the Academy of Medical Colleges endorsed clinical headings, so GPs can find key information in the summary more easily. Commissioners are also required to provide all reasonable assistance to providers in implementing electronic submission.
  3. Clinic letters Hospitals to communicate clearly and promptly with GPs following outpatient clinic attendance, where there is information which the GP needs quickly in order to manage a patient’s care (certainly no later than 14 days after the appointment). For 2017/18, the intention is to strengthen this by requiring electronic transmission of clinic letters within 24 hours.
  4. Onward referral of patients Unless a CCG requests otherwise, for a non-urgent condition directly related to the complaint or condition which caused the original referral, onward referral to and treatment by another professional within the same provider is permitted, and there is no need to refer back to the GP. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
  5. Medication on discharge Providers to supply patients with medication following discharge from inpatient or day case care. Medication must be supplied for the period established in local practice or protocols, but must be for a minimum of seven days (unless a shorter period is clinically necessary).
  6. Results and treatments Hospitals to organise the different steps in a care pathway promptly and to communicate clearly with patients and GPs. This specifically includes a requirement for hospitals to notify patients of the results of clinical investigations and treatments in an appropriate and cost-effective manner, for example, telephoning the patient.

Source: NHS England

Readers' comments (17)

  • Azeem Majeed

    These steps are potentially helpful but it’s important that the guidance filters down to all levels of hospital staff. We already have examples of NHS guidance (e.g. on the issuing of medical certificates for sick leave) that are often ignored by hospital staff because they are either unaware of their responsibilities or have never been trained in how to follow the guidance.

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  • This will be wonderful, if it happens, but I'm afraid it's flying pigs time

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  • "Unless a CCG requests otherwise"...and thats where nothing will change.

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  • Another brilliant coup by Hunt. Play primary and secondary care off against each other. Judging by the previous comments, its already working. The 24 hour discharge summary is a joke. In West Sussex it's already a CCG standard for providers. Result - hastily written and incomplete in many cases. Alternatively written days before discharge and omitting later clinical detail. The 24 hour rule puts more weekend pressure on the NHS. Wouldn't accurate and complete information in (say) 60 hours of discharge be more valuable?

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  • Only 7days meds, very dangerous. Discharged Saturday, gets pharmacy to request rpt. medication Monday. Letter processed GP surgery Tuesday and rot template amended. Whoops all the medication stopped in hospital has already been reissued. We need a repeat tempalate for medication that is compatible across all IT systems, primary and secondary care, so once changed, in any care setting, it is apparent to all service providers.

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  • Demonstrates nicely what a dynamic exciting specialty this is for all wanna be GPs.
    Do you wish to be considered an idiot for the rest of your career, do wish to go back doing the same jobs you did as a house officer, do you wish to see trivial disease and anything interesting and important give to someone else, do you wish not to be trusted to even request an MRI without a proper doctor seeing your patient first .......become a GP.
    I'm willing to bet next week's wages it'll change nothing.

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  • Anonymous | Other doctor28 Jul 2016 9:58pm
    What on earth are you going on about?

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  • I had to do a sick note on a NHS patient who had just had a CABG where the hospital team discharged him on the Friday, told him not to work for 6 weeks (and wrote this in the discharge report) but only signed him off work until the Monday and told him to see me for a further sick note. It will take years for this attitude towards general practice to change. This madness has to stop.

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  • Recently noticed a trend for hospital discharges to say "GP to chase up test result" on one occasion a biopsy result from endoscopy where cancer was possible.
    As hospitals have ever increasing pressure to discharge patients they off load onto GP. It will get worse as Hospital beds are closed to save money.

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  • Reference Dr Cox 28/7/16 11.36pm. It is surely not the responsibility of the GP to 'chase up test result' requested by secondary care. That responsibility must rest with the professional that requested the investigation. In similar circumstances, I have written to Clinical Directors in secondary care who, in fairness, recognise their responsibilities and have subsequently directed the juniors in their team appropriately. I would suggest that all my colleagues in general practice adopt a similar uniform and consistent stance. Slowly the message will sink in:- ask for an investigation and be prepared to accept the responsibility and accountability for sorting out the result. Perhaps our colleagues in the medical indemnity business might wish to comment?

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