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GPs go forth

The many disappointments behind this appointment


We GPs embrace uncertainty. So I’m not embarrassed to admit that when I refer a patient I’m uncertain what happens next, although I think it involves paperwork, passwords, and online booking and so on. But I’m fairly certain this process means patients can expect to start their treatment within 18 weeks of referral, because the NHS Constitution says so.

And what I am completely certain about is that the system is going wrong. It is not so much broken as splintered, comminuted, compounded and infected. And patients are suffering, which means, boy, do we suffer too.

We’re all dimly aware of low-level gaming, whereby hospitals don’t release appointments, meaning my referral remains in limbo and the NHS constitutional clock is paused. This has been accepted with a resigned shrug: if unattainable targets are set within an overstretched NHS, what do we expect? But things are getting seriously out of hand. I have around three interactions per day with patients dazed, confused and disgruntled by the hospital appointment system. Here are today’s examples:

The only consistent bit is that end-of-tether patients are inevitably sent back to us

1 A woman stuck in the usual ‘no appointments available yet’ holding pattern for a dermatology referral who switched her choice to another hospital, only to be told they’re now refusing our patients. Allegedly, they’ve had enough of the overspill.

2 A man with back pain I referred to the musculoskeletal service, triaged to an orthopaedic appointment after initial consultation with the physiotherapy practitioner, then bounced back to me, because the referral from physio to orthopaedics ‘did not fulfil the referral criteria’.

3 A man with a cervical disc prolapse seeking a neurosurgical opinion whose appointments have been declined by two centres of excellence for reasons lost in the ether of Planet Admin, despite referrals by me and the local MSK service and who, over the 12 months he’s been waiting, has seen his local MP more about this than he has a relevant clinician.

These are not appointments. These are disappointments. And they are causing appointmental illness. Yet the cycle continues, the only thread of consistency being that end-of-tether patients are inevitably sent back to us – to the point that, when I see or hear ‘refer back to GP’ or one of its variations, I want to inflict GBH on the perpetrator, though there’s no danger of that because their identity is hidden by the cogs of the machine.

What this means is, patients are having increasing problems getting appointments with me because those appointments are wasted with patients complaining they can’t get their appointments at the hospital, and that is a sick joke.

So I’d like to point out that the NHS Constitution also pledges to provide a positive working environment for staff and to promote supportive, open cultures that help staff do their job to the best of their ability. How about fulfilling that pledge right now? Starting by accepting that, once I have referred, my work is done. Thereafter, patients should have access to a referral co-ordinator. No appointment required.

Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at or follow him on Twitter @doccopperfield

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Readers' comments (13)

  • Well said. The truth is the NHS is on life support. Someone will have to be bold one day to pull the plug.

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  • When resources are finite and inept at delivering the visions from the IVORY TOWERS (NHS constitution, GMC, RCP, HEE, NHSI. NHSE......)its time to change them to what is actually acheivable. Common sense yeh!

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  • Waiting lists for going on a waiting list are crazy

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  • The system is /has Imploded.
    I cannot see anything on the horizon which might make it better. Stop all new initiatives and plug the gaps/ hold up the walls first please.

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  • The main CCG and orthopaedic department learning point from me writing a 'quality alert' about a man who had somehow developed a sinus into his knee join, and who was triaged to physio, and who, when he saw said physio in the orthopaedic department was not fast tracked to a consultant (it being their departments fault in the triaging) but instead was put to the back of the queue, not seeing an orthopaedic doctor until over 6 months from my initial referral, was that I shouldn't have used the word 'muppet' in my complaint, and needed some kind of warning!
    The system is utterly broken.

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  • Dear All,
    Well how's this for mad lunacy, our local eRS service has a deadline of 3 days during which we have (sic) to attache the necessary documentation. If they aren't attached within the 3 days they cancel the referral. So they helpfully send out reminders. The reminders are sent via their fax to e-mail to whatever system. These messages take 11 days to arrive in our in-boxes.
    So their "we might cancel your referral unless...." messages arrive 8 days after their deadline has closed.
    Simply brilliant
    Paul C

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  • Guys, don't be so negative.

    Don't see it as a barricade; see it as a bridge (/s).

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  • They same thing is happening locally too. Referring back to the GP! If I can sort it, I would not be referring in the 1st place.
    The article is spot on as usual "unattainable targets are set within an overstretched NHS, what do we expect?"
    But the GMC, CQC, NICE expects patients to have fantasy world class service and yet they setup more road blocks to prevent this. More rules, more audits, more you cannot do this to help, more paperwork, anything to put a spanner in to stop GPS helping unclog the system and of course provide more fees for them for more self created "work".

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  • In my area, orthopaedics and neurology routine appointments have become unworkable
    7 -8 years for a knee or hip replacement
    5 years plus for a routine neurology appointment
    Trouble is that the waiting lists are growing faster then the number of patients being seen so effectively you will never ever get an appointment at all....

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  • Faceless clinicians or admin cancel or delay the referrals, but who is left carrying the medicolegal risk. The only identifiable clinician is the GP, until they are seen in clinic

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