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GPs go forth

When a contract isn’t a contract

Editor's blog

Imagine for a moment that you installed a premiumrate telephone number for patients. Or unilaterally closed your list because you simply couldn’t take on any more patients. How quickly would you expect a call from your local commissioner for breaching your contract?

Trusts in England, though, appear to be able to ignore their contractual requirements with impunity.

I’ll let you behind the curtain. I’m writing this on my phone as I have a hospital appointment on press day that I couldn’t change. I’ve waited months for this appointment. The letter from the hospital says: ‘If you fail to attend without providing any cancellation notification you are liable to be discharged from our service, in line with trust policy.’

This is not a one-off. The NHS standard contract prohibits trusts implementing such blanket policies on discharging patients but as our cover investigation shows, this contractual stipulation is being routinely flouted.

Our figures show contractual changes introduced in 2016 have made absolutely no difference. The percentage of patients being discharged after a single DNA is pretty much the same.

Similarly, there has been little change in approaches to sending timely discharge summaries, or increasing consultant-to-consultant referrals, despite various diktats.

Trusts appear to be able to ignore contractual rules with impunity

The reason is commissioners are simply not enforcing the contract. We reported in April 2017 that not a single CCG had applied a sanction to a hospital trust for breaching its contract in this way. Our survey this month reveals 51% of GPs in England have complained about trusts breaching their contract, and only one (an NHS commissioner) said the CCG took any action.

Of course, CCGs know only too well the immense pressure secondary care is under and I can understand why enforcing this part of the contract is not a hill they are willing to die on when the whole system is in a mess.

But, to me, it demonstrates that commissioners still see GPs as (ironically) their secondary priority. First, these contractual changes were not some empty gesture – they were brought in because GPs are being buried under the workload dump resulting from trusts’ policies. The changes were wholly necessary and must be enforced, as NHS England confirms in our cover story. The benefits for GPs would far outweigh the effort needed from trusts to comply. The only possible reason not to enforce these requirements is that GPs’ time is valued less than that of trusts.

Second, we know that commissioners would go by the letter of the GP contract (even when those letters are unclear). As we approach Christmas, who can forget the commissioners’ heavy-handedness in telling practices they must open on Christmas and New Year’s eves.

Presumably, they are more concerned with GPs and practice staff getting those crosswords finished before Santa arrives than they are in relieving workload during the busier periods.

There is a lot of talk about integration and the system working together. Making sure trusts stop this unnecessary workload dump would be a signal that commissioners are taking this seriously.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at

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Readers' comments (8)

  • I think we need to encourage patients to sue the trusts.... perhaps stoke up a class action against one particular trust..... and lets see what happens.......

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  • When I was in practice, local Trust's IT was unable to cancel appointments - even when the patient had been rescheduled at their own request.
    This led to DNAs,GP calls/letters to patients upset patients ("I phoned the hospital & changed the appointment") upset consultants ("this patient somehow showed up in my clinic") & irritated GPs ("who on earth commissions an appointment system where you can't cancel or change appointments?!?").
    Have things improved since 2013?

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  • But....but....but.....CCGs were sold as GPs taking control of services and commissioning and that finally the dog would wag the tail.

    You mean to say we were lied to? Shocking.

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  • Vinci Ho

    As I wrote my comment under the original article of this matter(with expletives):
    (1) The GP hospital referral system has become an egregious caricature of itself; (a)Enormous number of GP referrals are being rejected and bounced back everyday( we already have stories of two teenagers who died during referrals to children mental health services) . (b) It is getting more unpredictable and user-unfriendly as far as electronic referrals for patients are concerned. The risk of failing to get the referral through increases as the referral process becomes more and more cumbersome. (c) Then one has this highly suspicious incompetence of mislabelling patients as ‘DNAs’ (of course , benefit of doubt being reserved as some patients DNA without good reasons) and immediately discharging patients back to GPs , incidentally against the hospital contract with NHSE as reported by Pulse .
    (2) Incompetence is worse than malevolence. I am questioning the intentions , conscious or unconscious , of NHS England on this matter , especially not too long after the infamous resignation of Dr Madan( I called it Madangate) .Am I right to say that the consequences of this totally dysfunctional referral system include driving a big wedge between primary and secondary care in NHS ? Do not forget that the new ideology of PCNs is also about developing integrated care systems (ICSs) with multiple integrated care teams (ICTs) ; PCNs/GPs are supposed to form alliances with their local service providers where acute trusts/hospitals are ‘big players’ . The harm and hypocrisy of this referral system is already well rooted before one can consider any ‘integration’ . Based on the trilemma theory , the system is totally obsessed with ‘integration’ while it is willing to sacrifice either democracy or sovereignty of both primary and secondary care .
    (3) We are heading towards a historic Christmas general election (incidentally on my 20th marriage anniversary!) , the political fiasco goes back to the starting point : Brexit or no Brexit , hence , sovereignty together with democracy but no integration Versus integration with sovereignty but no democracy (could be with democracy but no sovereignty in some instances ).
    It is ironic that we have a similar mess in NHS between primary and secondary care under the watch of this government and its Ministry of Plenty .

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  • General practice is free! It costs nothing to change pathways and put more work on us

    Coupled with a lack of respect towards general practice from consultants means that we get a double whammy

    CCG GPs im my experience want to look ‘clever’ in front of CCG managers and the hospital and pile more work on us

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  • What I'm surprised at Jaimie, is you expected it ANY other way.... almost betraying a naivety/ignorance....

    This is what happens when we 'agreed' to a bulk contract, with a huge power imbalance in favour of the state...

    Direct competition for/from the 'clients' is the only promoter of quality I'm afraid, and there is simply none of that in our current system

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  • Free leads to abuse and unlimited workload.

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  • what happens when we are not there to dump on any more? as a locum working in some practices with little or no partner input one sees these things not followed up because there is no one to follow them up. there is no continuity of care and the patients end up in A^E as emergencies. Its not in the hospitals best interest to dump on GP's - it will and it does back fire.

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