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GPs buried under trusts' workload dump

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)

  • The issue now will be the allowance to send all the information via email. Direct into clinical systems would be so much better and reduce paper and time in practice.

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  • Whilst this may or may not be a "divide and conquer" prior to a contract change it is only possible because of the unacceptable dumping by our secondary care colleagues....
    Re chasing results- if your local hospital has a GP Liaison officer then it's pretty simple to resolve- forward each letters on to them saying either they need to put you on the hospital payroll (standard GP locum hourly rate applicable) or they need to chase up their own results. I did this for about a week with the local hospital and the A+E department got the message and promptly developed a system to "chase" their own results. Hasn't happened since.

    The worst case of dumping I have experienced was Barts Hospital who introduced a new appointment system which promptly destroyed their waiting lists. They wrote to us about every one of our patients who they believed was still waiting to be seen saying "Please contact the patient and see if they still need to be seen, if so e-mail us back at [whatever it was], if we do not hear from you we will assume the patient no longer wants to be seen". I sent them all back marked "DIY- unless we say otherwise the patient still needs to be seen- try ringing them and asking- your IT issues are not my responsibility". Clinical Governance officer also got a rocket!

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  • I'll believe it when I see it.

    Meanwhile the battle with hospitals goes on. Not only dumping of work but asking us to prescribe inappropriately for unlicensed meds and meds which interact with patients' current meds-I see these errors almost daily.

    oh and 7 days of discharge meds is not enough they need at least 2 weeks.

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  • Its not just these, a couple more..
    Sending patients copies of medical letters, that are full of jargon and worrying then come in to get them deciphered! They should do a separate letter to the patient, explaining things in lay-terms.
    Other letters from clinic, tagging on the bottom a note for the GP to do a series of tests (sorry boys Im not your SHO). They should get their in house juniors to organise these.
    Going in for an operation, and giving the patient a sick note for 'x' days, when the usual recovery is weeks. Just do it??
    Combined these would easily save 10% of my appointments

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  • This week I had a letter from a consultant haematologist regarding a patient with a clotting disorder requesting that I refer him to the anticoagulant clinic!

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  • The fact that NHS England has to spell out what should be normal professional conduct tells you all you need to know about the shambolic dysfunctional mess that is the NHS.
    Perhaps if the JDs spent more time on writing timely and accurate hand overs of care(aka Discharge summaries) rather than whingeing about their spoilt Saturday afternoons, fewer patients might be harmed.

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  • To quote Victor Meldrew "I don't believe it"

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