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England GPs demand halt to mandated ‘advice and guidance’ before referrals


elective care


GP leaders have called for an end to hospitals being allowed to mandate the use of ‘advice and guidance’ before accepting GP referrals of patients to secondary care.

The England LMCs conference called on the BMA’s England GP Committee to ensure that ‘GPs cannot be mandated to use advice and guidance by commissioners or providers’, with 100% of delegates voting in favour.

Both other parts of the motion, which said GPs should be able to refer directly to secondary care ‘when thought to be clinically necessary without pre-referral interference’ and that if A&G is used it should be for secondary care to give advice to patients and prescribe if needed, were also passed with 98% and 57% in favour respectively.

Proposing the motion, Dr Jen Moss Langfield of Nottingham LMC said that mandating GP to use A&G as the single point of access for referrals is ‘rationing of our secondary care provision for our patients’.

She said: ‘Give us guidelines but give us the professional respect to decide with our patients when we have reached the point of wanting assistance and in what form that assistance should come. We will choose advice and guidance if possible, [but] that decision to refer is not something we want delegated.

‘We need to be firm about this, it’s a really dangerous path. We are the ones the patients are going to hold responsible for [referral] rejections, it won’t be secondary care, and we already have such a difficult time with getting our patients on side and realising what we do and realising how hard we work for them.’

‘A lot of extra risk’ will also be transferred, she added.

Speaking in support, Dr Asif Faizy of Hertfordshire LMC said A&G ‘pushes GPs to undertake work that they do not have training, competencies, experience and the time [to do]’.

He told delegates: ‘GPs are expected to operate as cardiologists for cardiology teams, as a dermatologist for dermatology teams and as a psychiatrist for mental health services – and so on – without resources.’

Meanwhile, a motion that said the GPC should explore ‘changes to the performers’ list regulations to allow consultant staff to deliver care within general practice’ with NHS England was passed as a reference by a slim majority – with 53% voting in favour.

Cambridgeshire LMC chief executive and chair of the UK LMCs’ conference Dr Katie Bramall-Stainer proposed the motion, saying it could be ‘the genuine triumph of an integrated care agenda if we give it a chance’.

She said: ‘Why not allow trained specialists the opportunity to support GP colleagues, why not allow groups of practices to directly employ consultants from relevant specialities?

‘Would you rather have a podiatrist, dietician, physician associate, or a consultant specialist working autonomously in collaboration with their GP colleagues, employed by those practices?’

She added that the motion is ‘not seeking to replace’ GPs but aims to ‘retain GP posts for GPs to return to’ when there is a new GP contract that ‘entices them back’. 

Dr Bramall-Stainer told delegates: ‘This wouldn’t merely be dragging and dropping a secondary service, it would be the potential, implement, evaluate and refine the out of hospital model in a manner that will actually support us as clinicians.’

Speaking against the motion, Dr David Haines of Dorset LMC said it was the ‘worst proposal’ he had ‘ever seen’ in 36 years working as a GP and that it ‘smacks of desperation’ and would ‘undermine’ general practice’.

Dr Reshma Syed of Kent LMC added that it is ‘offensive that there is a notion that consultants can deliver care within general practice’ when they have ‘no concept of what general practice is, what it stands for and what care is carried out in the community’.

She said: ‘Have we no pride in our own speciality, which has taken years to master? We are the jack of all trades in primary care medicine and we should be proud of this.

‘I am sick of NHS England thinking that all allied health professionals and consultants can do this job better than us, to serve as a bandaid to the haemorrhage of GPs. No, they can’t, it is a false economy.’

There were no speakers in favour of the motion, which comes after NHS England’s GP access plan said that the £250m winter access fund could be used to bring in retired secondary care doctors including geriatricians to help boost appointment numbers.

GP leaders attending the conference also voted in favour of a motion condemning workload dumping from secondary care and calling for a ‘nationally-funded hospital discharge system’.

Speaking in response to the motion, GPC clinical and prescribing lead Dr Preeti Shukla said that secondary care workload dumping ‘needs to be dealt with as a priority’.

She said: ‘Lack of infrastructure in secondary care has led to a lot of inappropriate transfer of workload across to us and we just don’t have the capacity to deliver it.’

And she added that the motion should be ‘all encompassing’ rather than focussing on secondary care since other services that ‘seem to be transferring their work to GPs’, such as community services and ‘other services in primary care’. 

‘We need to have a look at a system as to how these requests don’t end up with the GP trying to sort everybody out’, she said.

Pulse revealed earlier this month that an LMC has called for GP practices to be paid £12.50 per A&G episode to resource the extra workload.

It follows a major London trial assessing A&G as the single point of access for referrals and a CCG target to cut GP referrals by 65% through A&G.

NHS England has set a national target requiring GPs to use A&G for 12 out of 100 outpatient attendances by March next year.

Motions in full

AGENDA COMMITTEE TO BE PROPOSED BY NOTTINGHAMSHIRE: That conference is concerned about a lack of cohesion between general practice and secondary care and calls on GPC England to ensure that:

(i) GPs cannot be mandated to use advice and guidance by commissioners or providers PASSED 

(ii) GPs should be free to refer to a secondary care colleague when thought to be clinically necessary, without pre-referral interference PASSED

(iii) if advice and guidance is used, then it is be the role of secondary care, not general practice, to dispense the advice to patients and prescribe where appropriate. PASSED

CAMBRIDGESHIRE: That conference sees Integrated Care Systems as having the potential to support the general practice workload crisis so calls on GPC England to explore with NHSEI changes to the performers’ list regulations to allow consultant staff to deliver care within general practice PASSED AS A REFERENCE

SHEFFIELD: That conference recognises the negative impact that inappropriate transfer of workload from secondary care to primary care is having on GP morale and recruitment and calls on GPC England to negotiate with NHSEI for a nationally-funded hospital discharge review system that will:

(i) prevent contractually inappropriate requests PASSED

(ii) help develop new discharge pathways appropriate to care in the community PASSED

(iii) include an educational element for all clinicians PASSED

(iv) create more clinical dialogue between primary and secondary care. PASSED

Source: BMA

READERS' COMMENTS [8]

John Glasspool 25 November, 2021 7:17 pm

Look, folks: the government regard GPs as a very low form of life. Much less clever that “proper” hopsital people. The next step will be that GP training will be reduced to two years but thereafter GPs will have to be known as “Apothecaries”.

Samir Shah 25 November, 2021 7:47 pm

Agree JG, or maybe a ‘Physician’s Associate’s Associate’.

Samir Shah 25 November, 2021 7:55 pm

GP is a speciality in it’s own right. always has been. Putting effectively a barrier between GPs and secondary / tertiary care just impairs our ability to treat our patients.
How can it be called ‘integrated’ care while at the same time putting barriers up?

Patrufini Duffy 25 November, 2021 7:58 pm

Agree JG.
The pawn on a dirty corrupt and broken chess board. With new rules, you can’t move forward. When you do CPD there is always a slide by a Consultant “When to Refer” – that will be updated to “Never – depending on A+G gimmick”. Another dead end proposal because hospitals are the place to protect and no where else.
The NHS is not fit for purpose anymore.

Hewa Vitarana 25 November, 2021 10:44 pm

AgreeJG,
The government and NHSE also treat GPs as a low form of life.

Vinci Ho 26 November, 2021 6:44 am

Well , then logically and realistically ,
NHS is becoming the very low form of service because we(GPs)!are treated as very low form of life.
Of course , those government propaganda media will disagree 😈

Andrew Jackson 26 November, 2021 9:56 am

A+G may have a long term role to play in managing patients health issues but only if it is done INSTEAD of something else.
My stats may be wrong but approx 1 in 10 consultations lead to a referral. When I do a referral there is no additional work involved and I can usually not plan to allocate more clinical time to this situation.
If I see 30-40 patients per day then that is roughly 3-4 referrals per day and everyone of these will in effect need an additional appointment to sort out ie 10% of each days capacity is lost.
We have no chance of doing another 10% of work at the moment as there isnt the workforce, even if we are paid.
We could always hold back 10% of each days appointments to be filled for dealing with the A+G but I dont think this would be very popular with NHS England.

Mark Fentanyl 2 December, 2021 3:58 pm

It will be the great game. A and G will soon be delegated to the research registrar and the junior – you won’t find the consultant grade on the end of a phone, especially when the secretary quit two months ago. Imagine the creative effort going on in the hospital, with management auditing the number of successfully bounced referrals and creating a league table. Have you done the Magnesium? well done, but what about the Manganese levels? Have you tested for Lyme disease? – you’ve not, well send off the Portion Down and if they deem the test appropriate you’ll get the results in a few weeks. Not done a PET scan pelvis/ lower limb nerve conduction/ cytochrome antibodies? Oh dear, get them done and get back to us…