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Hospitals banned from requesting re-referrals from GPs

Hospitals will be prevented from automatically discharging patients who do not attend an outpatient clinic appointment into the care of GPs as a blanket policy, in a bid to reduce the workload dump on GPs, NHS England has said.

It has also told hospitals they would be allowed ‘onward referrals’ of patients to other parts of the hospital, meaning GPs will not be required to refer the patients themselves.

It is part of NHS England’s attempts to reduce GP workload through its General Practice Forward View.

NHS England said it was changing the NHS Standard contract to ’relieve some of the administrative burden on practices’.

It said the changes mean ’hospitals will not be able to adopt blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for re-referral’.

Under the contractual changes, ’unless a CCG requests otherwise, for a non-urgent condition related to the original referral, onward referral to another professional within the same hospital is permitted, and there is no requirement to refer back to the GP. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions’.

NHS England is also looking to cut workload burdens caused by commissioners requiring mandatory training from GPs, saying it will review and reduce requirements for training in areas such as fridge procedures, fire safety and complaints handling to ensure ‘a far more proportionate approach is taken.’

It added that it would also review the impact of appraisal and revalidation requirements.

The package involves a string of other new policies to stop secondary care dumping work on general practice.

NHS England said the plan would contractually require hospitals to:

  • Publish evidence of having taken account of GP feedback when considering service development and redesign;
  • 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;
  • Provide summaries in the standardised format agreed by the Academy of Medical Royal Colleges, so GPs can find key information in the summary more easily;
  • Communicate clearly and promptly with GPs following outpatient clinic attendance, where there is information that the GP needs quickly in order to manage a patient’s care (no later than 14 days after the appointment). For 2017/18, to strengthen this by requiring electronic transmission of clinic letters within 24 hours;
  • Organise the different steps in a care pathway promptly and to communicate clearly with patients and GPs;
  • Notify patients of the results of clinical investigations and treatments in an appropriate and cost-effective manner, for example, telephoning the patient;
  • Supply patients with medication following discharge from inpatient or day case care and 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).

NHS England added that GPs should notify their CCG in the event that the contract is not being followed.

The plan also proposes to relieve GP workload with a £30 million national programme called ‘Releasing Time for Patients’.

Run over three years, NHS England said the programme would introduce new ways of delivering care, such as telephone consultations or different use of other professionals in the general practice workforce. The programme, which was piloted in 2014/15, will launch in 2016/17 and run for three years.

The programme will:

  • Gather and disseminate successful examples and measure impact. This will include support on implementation of the Ten High Impact Actions, and a specific focus on addressing inequalities in the experience of accessing services, where there are national trends.
  • Host local learning programmes with expert input, supporting practices and federations to implement high impact innovations which release capacity and improve patient care.
  • Build change leadership capabilities in practices and federations, enabling providers to improve quality, introduce care innovations and establish new arrangements for the future.

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Readers' comments (21)

  • Hospitals were apparently banned/warned about loads of stuff previously for dumping on GP land:

    1. I still get patinets presenting needing sick notes because hospital staff cant be arsed to find one. If I dont issue and try to redirect back to the hospital Ive even had the hospital staff encourage the patient to lodge a complaint
    2. Urgent prescriptions for antibiotics from a world renowned orthopaedic centre of excellence for asymptomatic bacteruira continue to arrive.
    3. Results 'GP to chase' continue to arrive
    4. Re-referrals down the corridor continue to arrive.

    In summary, little is addressed, and it will be up to us to police the system.

    Thanks a bunch.

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  • Killer phrase "unless a CCG requests otherwise" - in other words, all those local consultant-to-consultant policies will make this utterly meaningless as each CCG tries to get a quart of demand into the pint pot of their budget allocation.

    Net impact on GP workload - Sweet Fanny Adams.

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  • @09:27 - It's partially because while this information is well publicised to those working in primary care, it's barely touched upon in Foundation Doctor training - I occasionally (annually) get an email with an ignorable heading, reminding us not to do the above - but there's no teaching face-to-face, and no understanding on a consultant level to back it up. Just yesterday I was asked by a consultant I thought compassionate and intelligent, to get a GP to chase a SPECT result and refer accordingly....needless to say this was promptly changed to "the discharging team will chase and refer appropriately".

    Secondary care need to develop empathy and a better functional knowledge of what GPs do, and can only do so by understanding why GPs ask what they ask. I don't think the above is driven by laziness, ineptitude or malice - I think we're genuinely not taught what an IDL is for, only that it needs done as per an overbearing discharge coordinator, and ASAP. Nor are we told how it is used in the community, and what is/isn't acceptable to ask a GP to do - I only learnt this during my ST1 job in GP. Better teaching of junior docs is required - even just calling them and (crucially) politely/kindly explaining why information is required, so they can then learn and avoid it in the future.

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  • Oh and of course I mean that teaching should be delivered by postgraduate teams, hospitals and consultants - not GPs - but opportunistic teaching while discussing cases on the phone can be really useful.

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  • When I was a GP Exec member of a CCG, this sort of arrant nonsense was the bane of my life, but NHSE has given us the ammunition for CCGs to fire at Trusts. Regrettably the problem rests not only with the managers but with our clinical colleagues, junior and senior, many of whom failed to see the imperative of communication in managing the safe handing over of their patient to a third party(us) on discharge.They seem happy to dump work on us, then demand our sympathy because they would rather not work on Saturday afternoons.

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  • Ahem!!

    These GP onward referrals were forced upon us hospital doctors! Many a GP protesting "they have to refer", to our colleagues"down the corridor", rather than us in the hospital.

    Now it seems the silly process of GPs having to onward refer everything is being blamed on hospital doctors!! No memory of the past I suppose?

    It smells of divide and cnqr.

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  • @11:07

    I am fairly certain the above 'new' situation described is actually, contractually, no different to the situation now.

    Consultants ARE ALREADY allowed to do onward referrals for the same condition. For example if I send someone to a respiratory consultant - but he decides it is heart failure, he is allowed to refer on to cardiology or the heart failure nurse.

    What you are not allowed to do is see someone in respiratory clinic with asthma - then do a referral to dermatology because they ask you about their psoriasis during the consultation - that has to go back to the GP.

    The mantra you are following comes internally from hospital managers. Onward referrals incur a follow up appointment - which is less funding for the hospital. And if the consultant gets it wrong and refers the psoriasis case above - the hospital might not get any funding at all. That is why the managers blanket tell you to not refer anyone internally.

    But... creating extra work for GPs, because you want the higher fee; or because you are afraid your hospital's consultants won't follow the rules correctly is just plain wrong. (By the managers, not clinicians)

    Finally - I hope most consultants already realise that internal referrals for urgent and 2ww referrals have always been allowed. Pissing around with those just risks more errors and associated litigation.

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  • This is the same NHSE that is desperate to dump all specialist prescribing (e.g. transgender) onto GPs with no consultant shared care

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  • Does get to grips with why the patient DNA in the first place does it NHSE? But you will never confront the smartphone enabled patient will you who cannot call to cancel an appointment?

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  • The consultant at 11.07 is absolutely right.The CCGs were behind the insistence that GPs must "vet" internal referrals. Apart from the vast majority being appropriate anyway, who in their right mind would bother going to the trouble to not refer on their advice and leave themselves open to complaints?

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