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A faulty production line

GPs told to refrain from referring as hospital declares early-season black alert

A hospital in Cambridgeshire has asked GPs to refer their patients elsewhere after declaring a ‘critical internal incident’ because of a lack of beds.

Addenbrooke’s Hospital, part of Cambridge University Hospitals NHS Foundation Trust, sent out a letter to GPs yesterday morning asking them to refer patients to the community urgent care support team ‘whenever possible’.

The letter says the incident, which is still ongoing, is due to ‘bed capacity issues’.

GP leaders warned it would create additional work for practices and that such an early-season 'black alert' was not boding well for winter.

The letter says: ‘The Medical Decisions Unit (MDU) is currently full and there are patients within the Emergency Department awaiting admission that cannot be placed into inpatient beds due to a lack of bed capacity.’

The letter adds that elective patients are on hold and patients are being reviewed for potential cancellations.

The letter tells GPs: 'Whenever possible please refer patients to the community urgent care support team ... The joint emergency team will respond within two hours and will attend to patients who are aged 65 years and over in their home environment.'

Dr Robert Morley, policy lead for the BMA’s GP Committee, told Pulse: ‘While general practice is getting used to these alerts, it is indeed unusual to get such a bed crisis so early in the autumn and it doesn’t augur at all well for the winter to come.

‘Needless to say general practice has to deal with such workload crises all year round and does not have the safety valves that hospitals can call upon.’

He added that the critical incident would 'absolutely' increase the amount of work for GPs in the area.

A Cambridge University Hospitals spokesperson said the trust decided to declare the incident ‘as a result of increased demand on beds’.

He said: ‘These situations are not uncommon in hospitals that are seeing a year-on-year increase in demand. When appropriate, we also remind the public not to attend A&E unless it is an emergency and point out other treatment options such as GPs, pharmacists and 111.’

This comes as NHS England statistics reveal that the percentage of A&E attendances admitted to hospital or discharged in four hours or less fell from 87.9% in 2015/16 to 83.7% in 2016/17 in hospital trusts with major A&E departments.

Nationally, major A&Es have missed the target every year since 2010 when 96.1% of patients were admitted or discharged within four hours. 

Commenting on the national statistics, Justin Madders MP, Labour’s shadow health minister, said the Government's 'underfunding of the NHS' had 'caused chaos for patients and even in the height of summer key targets are being missed and waiting list numbers are rising'.

BMA chair Dr Chaand Nagpaul said: 'The crisis in the NHS is across the board – with a lack of hospital beds and services, A&E departments struggling because of an overstretched system, and GPs increasingly unable to get their patients treated within adequate timescales...

'The Government has so far failed to grasp the seriousness of the situation. The NHS isn’t at breaking point because of front-line financial mismanagement, or poor decision making, but because of the conscious, and constant, underinvestment in our health service.'

Pulse has previously reported that the BMA has declared the winter crisis a 'year-round norm' with an analysis that shows that trusts' performance this winter hit record lows, despite mild weather and no major flu or norovirus outbreaks

Doctors voted at this year's BMA Annual Representitive Meeting that GP practices should also be able to declare 'black alerts' when their surgeries are at maximum capacity, the same way that hospitals do.

Plans to put GPs in A&E to take the pressure off

In March, the Chancellor announced plans to spend £100m on a GP triage service in A&E departments, with every A&E expected to run a triage service by October 2017.

Pulse found that 420 GPs would be needed to run the service, with those working in A&E to have their pay capped at £80 per hour.

Most trusts have said they are planning to recruit around two GPs to cover 15-hour days and are working with GP leaders and CCGs to recruit the GPs.

However, concerns have been raised about the safety of the streaming services after a patient died as a result of being diverted to a pilot GP ‘streaming’ project designed to relieve pressure on A&E.

Readers' comments (26)

  • 'Whenever possible please refer patients to the community urgent care support team ... The joint emergency team will respond within two hours and will attend to patients who are aged 65 years and over in their home environment.'

    Did they remember to add: 'They will diagnose a UTI and you will be called to see the patient later in the week, when they will be admitted to hospital and their subdural haemorrhage and / or acute kidney injury will be treated. The families will blame you for the delay in diagnosis but will be happy the hospital did everything they could. You will have to answer to the GMC, CQC, criminal and civil courts and 60 billable hours of solicitors time will be used to investigate and debate your 10 minutes of contact with the patient.'

    'Following a prolonged hospital admission the patient will be discharged on a friday afternoon to a nursing home whose patients are registered with another practice so he/she can 'die at home'. No one from the hospital will contact the new GP surgery to tell them a patient is being discharged to a new home and GP to die. The district nurses will call that afternoon for the new GP to urgently rewrite the drug authorisation forms for morphine and other strong drugs. He/she will be encouraged to sign a new DNAR form without meeting the patient as the font on the hospital form is incorrect and not accepted in the community.'

    'The patient will die at the weekend and the new GP will spend several hours messing about with documentation related to the death over the following week, as they met the patient on the preceding friday whilst visiting the home. The relatives will book an appointment with the births and deaths registrar for Tuesday morning and will write to NHSE with a written complaint that the death certificate wasn't ready in time. The certification will not be ready for a week as the hospital discharge makes no logical sense and is unreadable. The cremation papers will take longer as the old records are stuck with Capita and it is unclear if the patient had any operations in the year before death, or what kind of disseminated cancer they had anyway.'

    'The hospital chief executive will use the experience of managing a bed crisis as a positive example on his C.V. He will be made redundant from his job and be paid £2000/day to advice a neighbouring trust on how to deal with a bed crisis. His original trust will employ the chief executive made redundant from the 2nd trust as an interim chief executive for £2500/day.'

    'The CCG Chief Executive will talk at conferences about how they have the highest number of patients who 'die at home' and will encourage clinicians to treat patients 'as they would treat their grandma'. Her grandma is in a state funded nursing that smells of urine. The staff work hard but leave to a better run establishment for a more liveable wage when their English is good enough.'

    'The family will start a charity and advocacy group for patients with subdural haemorrhage and acute kidney injury, resulting in an article in Pulse magazine titled, 'GPs urged to consider subdural haemorrhage and acute kidney injury in the elderly.'

    'The GPs originally involved won't read the article as one will be surfing in Australia and the second will be tending to their garden as part of an aim to become self sufficient and forget his previous life as an NHS GP.'

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  • Why are GPs constantly told that we need to be the solution to the problems that exist in other parts of the system (and over which we have no control)?
    If there is not enough capacity in A&E or hospital beds, that is the problem that needs sorting out. It won't get sorted out until there is media attention and pressure on the politicians.
    Dear Cambridge GPs - if you feel a patient needs an urgent hospital assessment, please discharge your professional duties and send them in. Do not risk their lives (or your careers).
    If the hospital team then think they can be managed in a community setting, let them discharge them and take clinical responsibility for them at home for the period of their illness.

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  • Cobblers

    Enjoyable and exceedingly apt piece BigAndSmall.

    However this article needs a short answer. And the answer is in the form of Q&A.

    Q. Is the patient you are assessing treatable safely in a Primary Care setting?

    A If the answer is "No" then get that patient to the shiny building where machines go 'beep' via the big white taxi. Go to ED directly. Do not discuss this with any admissions team or anyone else. (Your faxed 'do the needful' letter can follow)

    The decision to admit becomes theirs, along with the responsibility, and the disposition of the admission is also theirs.

    You can get on with doing what you do, see Primary Care patients. And frankly it isn't as if you are sitting on your arse twiddling your thumbs.

    (Tongue only very slightly in cheek)

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  • @BigAndSmall

    I would find your post funny if it wasnt the absolute truth! Though a reflexive snort did sneak out.

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  • @BigAndSmall

    One of the best comments I have ever read on Pulse.

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  • Their is no memo going around hospitals saying "please be aware our local GP colleagues are at capacity so please can we delay any possible discharges and make sure all necessary tasks are completed prior to discharge and discharge letters are up to date"
    I would suggest we treat the patient exactly as you normally would

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  • Bloody good BigAndSmall. Spot on.

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  • BigAndSmall - I agree - not satire but truth.

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  • @Bigandsmall
    Quite brilliant.
    (It was satire wasn't it?)

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  • Big and small- brilliant
    Please post the same on

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  • Lack of hospital beds is a management problem.
    It is not a General Practice problem.(We have plenty of our own, after all.)
    Let them manage their own problem, which I understand hospital managers get rather well paid to do.

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  • Surely if all the beds are full and A&E is full of patients waiting for beds then all those patients referred in or self-referred NEED to be in hospital or the clever Doctors would have sent them all home back to us?
    I just don't understand why it always falls on us, we refer in we DO NOT admit them that is up to the Consultants on call. If there is a problem it lies with them….

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  • ...I can only assume Bigandsmall is either one of my own partners in disguise or has a mole in our practice as the accuracy of your description of these incidents is uncanny!

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  • So true BigandSmall!

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  • BIGANDSMALL you could write a book on nhs today. I am sure it will be a hit.what a brilliant description of reality of nhs. it .looks like you have seen it all as we all have.
    my motto has always been to save your skin and make sure patient and relatives know what is happening and why.
    thanks for lovely input. true and amusing.

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  • Rogue1

    Big and small,
    Brilliant piece, if it weren't so close to the truth you want to laugh.
    Whenever I get messages like this Im almost tempted to send a few more their way. After all I don't admit, its the Dr in A+E that does

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  • BigAndSmall, I do believe you are today's Winner of the Internets :-)

    We regularly get emails saying that the local hospitals are full and could we please avoid sending patients in unless it's really necessary. Quite right, too. Everyone knows that GPs have so much time on our hands that we go trawling round our patients' houses looking for people to send to hospital just for our own entertainment, and that patients like the hospital experience so much that they pester us to admit them even when they're not ill.

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  • 5 stars for Bigandsmall :-)

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  • Perhaps we could put our uber successful leaders in charge at the UN and then they could also solve the Korean Crisis as well........
    Captain Blackadder: You see, Baldrick, in order to prevent war two great super-armies developed. Us, the Russians and the French on one side, Germany and Austro-Hungary on the other. The idea being that each army would act as the other's deterrent. That way, there could never be a war.
    Private Baldrick: Except, this is sort of a war, isn't it?
    Captain Blackadder: That's right. There was one tiny flaw in the plan.
    Lieutenant George: O, what was that?
    Captain Blackadder: It was bollocks.

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  • And don't forget that we GPs will be blamed for patients turning up to A&E to be reviewed or needing to be admitted because they couldn't be referred. No doubt there will be an increase in the £21 million spent on 'consultants' employed to suggest further cost cutting exercises. Meantime I will try and stay as healthy as possible and not become a patient!

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  • Bigandsmall - brilliant.

    I suggest a GP does not change behaviour in response to such requests. Do what you know is right for the patient in front of you even if that may mean some delay at the hospital end.
    Think about it, only then, eventually, after 'The Big Winter Crisis of 20...' will things change.

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  • BigAndSmall....that is the funniest posting I have read in a long is time you put him/her on the pay roll as your new columnist.

    Regarding ''black alert'' warning....same old crap every year, best ignored...if patient needs to be admitted they need to be admitted..end of story.

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  • Those emails get binned. If the patient needs admitting they get admitted. End of

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  • Please get BigandSmall to do a column for pulse! That is the funniest thing I've read for ages, especially love the bit about the chief executives not sure whether to laugh or cry!

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  • Hmmm, as Professionals...we need to shine a more positive light on such issues.

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  • Just Your Average Joe

    The comment from Big and small makes the article worth reading!

    Its what most of us sadly know looks like satire but is dangerously close to brushing true reality.

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