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Independents' Day

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)

  • David Banner

    “These are not appointments. These are disappointments”
    Quote of the year!

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  • Tony, I was only going to give you 4 stars, then I realised you were saving something back for next time:
    What is this marvellous NHS constitution you rumour of???
    Is it available to read, or only by appointment?

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  • Exactly. I used this word to a patient only this week. It was disappointing that she received a diagnosis of Alzheimer's when she went on holiday with her family to Dubai rather than wait around here. She had of course been discharged from the hospital waiting list for not responding to a letter she had never received.

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