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GPs fear new hospital discharge guidance will lead to workload dump

NHS England, RCGP and the BMA have come under fire from GPs over a new jointly produced guide advising on how patients should be discharged from hospital.

Grassroots GPs raised fears that the document, published earlier this week, could lead to hospitals expecting practices to follow up all tests, but the GPC argued that the document was intended to have the opposite effect.

One GP tweeted that the guidance ‘would seem to contradict GMC Good Medical Practice and BMA advice’ while another said ’why produce a document encouraging more dumping/ directing of work into primary care?’

NHS England has today amended one point in the guidance following criticism, but GPs Pulse has spoken to said the risk was not averted, because the document remained too open to interpretation.

The point had said that:

  • ‘Where a consultant delegates responsibility for any tasks around the communication of diagnostic test results to general practitioners, they should ensure clinicians given the task understand and fulfil that responsibility’.

But this was changed to say that:

  • ’Where a consultant delegates responsibility to another team member for any tasks around the communication of diagnostic test results to general practitioners, they should ensure that person understands and fulfils the responsibility’.

But this was not the only concern raised by GPs.

The document also says that 'every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test’, which some argued contradicted existing BMA guidance which says it is the clinician ordering a test who has to follow up on it.

Dr Hussain Gandhi, Chair of RCGP Vale of Trent, said: ’As a working GP my interpretation of [this principle] is still that NHS England is instructing that GPs will face responsibility of investigations they have not requested.  This is against current BMA and GMC guidance and puts patients at risk of duplicate management and wasting vital NHS resources.

‘It is the guiding principles and the organisational thinking of NHS England that needs changing not just the odd word.’

Dr John Cosgrove, an RCGP council member and GP in Birmingham said: ’I am concerned that [the standards] will result in GPs almost routinely being expected to follow up results of tests requested by secondary care, who may cite extraordinary pressure - which if NHS demand and resource pressures continue may well become routine.’

But GPC clinical and prescribing subcommittee chair Dr Andrew Green, who advised on the standards, said that there was 'never any intention from NHS England that this should facilitate delegating responsibility to GPs’, pointing to a principle in the document which say that ’the clinician who orders the test is responsible for reviewing, acting and communicating the result and actions taken to the GP’.

He said: ‘I understand concerns have been raised about “dumping” of results on GPs, relying on GPs’ duty of care to their patients, however these concerns are unfounded, as hospitals behaving in this way would be clearly in breach of the first principle.

‘This document should provide LMCs and commissioners with the tool they need to address this should it happen.’

However, Dr Zoe Norris, from the grassroots action group GP Survival said she 'was not madly reassured' by the revised document.

Dr Norris said: 'It leaves room for ambiguity – it has taken GPs this long to be firm and realise actually we shouldn’t be accepting this workload because we’re too pressured, we don’t want to now go backwards because there is confusion over the wording, it seems ridiculous.'

RCGP chair Dr Maureen Baker said that the document had ’understandably been causing consternation amongst our members’.

She said the RCGP 'contacted NHS England as soon as the issue came to light to raise our concerns’.

Dr Baker said: ’As a result, we understand that an amendment is being made to remove the suggestion that consultants can delegate responsibility to GPs (Standard 5).

‘We will highlight to NHS England any other points that require clarification – and we will be working with the Academy of Medical Royal Colleges to make sure that misunderstandings like this do not happen in future.’

NHS England said that 'the standard has already been amended in response to the concerns raised’.

What does existing guidance say?

BMA guidance on ‘receiving and viewing results ordered by another clinician’ state that ‘until an explicit code of practice is agreed, clinicians should assume that the ordering clinician is responsible for receiving and acting upon results and should not assume that others who can view the result will take action’.

Meanwhile the GPC’s recent ‘Quality first’ guidance offers GPs templates on how to reject requests ‘to chase/act upon the results of investigations requested by hospital (this is the responsibility of the hospital doctor)’.

Readers' comments (33)

  • Ensure every abnormal result not ordered in primary care leads to a corresponding hospital outpatient referral to discuss results.

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  • Rogue1

    So if hospital does 'dump' results onto general practice, the author states this is 'clearly a breach of the first principle'. Who do we report the hospitals too ?GMC,NHS England

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  • The 'first principle' needs to be reiterated at every opportunity within this document or it will be ignored. The GPC have forgotten the pressures junior doctors are under to end each 'episode of care' and to equate this with the end of 'episode of responsibility"

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  • I am most relieved to see this clarification of Standard 5. Maureen Baker, NHS England and others are to be congratulated for their work to achieve such a rapid revision.

    I remain concerned about elements of this document, however.

    The second guiding principle ("Every test result received by a GP practice for a patient should be reviewed and where necessary acted on by a responsible clinician even if this clinician did not order the test.") sounds like a sensible safety net. However, how is the GP to know whether or not the result of a test they did not order has been acted on by the requestor? Equally, how can the requestor of any test know that the GP is competent to act on the results of a test that they might not be familiar with?-

    Similarly, Standard 7 ("Appropriate systems and safety net arrangements should be in place in primary and secondary care to ensure any follow-up diagnostic tests required after discharge are performed and the results are appropriately fed-back to patients.") opens up potentially unsafe ambiguity about the responsibility of post-discharge tests, especially if discharge summaries are delayed. I am sure every GP has received a discharge summary advising blood tests to be carried out BEFORE the discharge summary actually reaches the GP!

    GPs should not be the default safety net for everything. Requestors of tests should retain responsibility for arranging them and actioning the results and should ensure that they maintain reasonable safety nets.

    GPs are not community house officers. If a hospital doctor has made the decision that a test, prescription or referral is required, they should arrange that. If, on the other hand, they believe that the opinion of a GP (who is well placed to know what can be arranged in the community) would be helpful, they should advise the patient to consult their GP on a routine basis after the discharge summary or clinic letter has been received by the GP.

    I fear this guidance actually INCREASES the risk that post-discharge tests will not be arranged or acted upon by introducing ambiguity in responsibility. BMA guidance in this area is much clearer http://tinyurl.com/dutytestprescribe and should stand.

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  • So then, for the avoidance of doubt, patients will be asked to attend hospital phlebotomy dept for all tests not required by me in their GP management. There will be no transcribing of specimen envelopes, electronic discharge letters saying "u&e 3 days" will be printed out and the patient advised to attend hospital, same for outpatient letters.

    We only end up with this work because we do not push back and because we like our patients and wish to make their lives easier.

    However, those days are gone.

    Not paid = no job, no job = no responsibility for that job, no responsibility = no worries.

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  • There already is a massive dump of secondary care work into GP land. We are viewed as their house officers. How is this news? We allow it to happen as we are weak

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  • good old rcgp and gpc - with friends like this who needs enemies ?

    have fun with pharmacists and PAs as clearly you have no interest in supporting GPs anymore.

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  • Let's get this straight - this guidance was agreed with the BMA and RCGP and now the RCgP are asking for changes - did they read it???

    That's why I stopped my subs to both - they need to help GPs who actually work and don't spend their lives in meetings.

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  • So gps are going to be pimped out by the BMA and RCGP!
    Not only this, I cannot imagine gps will even get paid for this?? So this is abusive behaviour against gps.
    What gives gives these organisations (which gps are forced to pay for) the right to make gps work for free? Not only this but if gps cannot charge for this impossible work (which goes against these organisations own guidelines as it demands docs to be psychic to mind read the thoughts behind other's treatments) then it effectively forces gps to actually using their own money for supporting their time to do the work.
    So when did these organisations turn into abusers and why do gps still tolerate this abuse?

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  • Isn't general practice a dumping ground anyway?

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