GP leaders concerned as ICB ‘single point of access’ blocks direct access to MRI

Exclusive GP leaders in North East London have raised concerns about a ‘singe point of access’ system for musculoskeletal referrals, which has caused loss of direct GP access to MRI, delays, and patients being sent back to general practice.

NEL ICB is pushing for implementation of MSK single points of access in all places in its area, including changing GP direct access to MRI to ‘reduce activity’ and ‘deliver cost savings’ that the ICB said would be ‘reinvested into MSK community services’.

The ICB said that the system is meant to ‘enable the managing of more MSK patients (80-90%) in the community’ and to enable secondary care to ‘meet their 18 week RTT target in orthopaedic services, improve conversion rates, reduce discharge at first appointment’.

But the LMC said that the system risks creating ‘additional barriers for patients’ and ‘extra workload for practices’, with patients being sent back despite already having received specialist input and GPs being left to manage ‘understandable anxieties’.

It told Pulse that direct GP referrals for MRI scans have been replaced with a system where one of the community providers sits in the middle and assesses the referrals, but that this has created a backlog due to a lack of staff to do the assessments.

It comes after a group of hospital trusts in North West London decided to pause plans for a single point of access for referrals, following concerns that this would prevent GPs from sending referrals without seeking advice first.

GP practices in England are required under this year’s contract to use advice and guidance (A&G) across specialities ‘prior to or in place of a planned care referral where clinically appropriate’, with single point of access routes to be finalised locally by 1 October.

In NEL, the implementation of single point of access has meant that GP direct access to routine MRI has been restricted, with routine MRIs ‘not recommended for MSK conditions in primary care’.

Dr Asad Ashraf, Waltham Forest LMC chair, said that the end of direct GP referrals into MRI services means longer delays for patients as requests sit with community services awaiting approval.

He said: ‘There has been no decrease in MRI capacity, simply the addition of an understaffed additional layer of bureaucracy is leaving patients waiting for diagnostics and GPs managing their understandable anxieties.

‘This is a particular problem in Waltham Forest, where a substantial backlog has built up, but still significant in the other boroughs affected.

‘Given the ICB is committed to this approach and has allocated funding, they need to either fill these posts quickly or resume direct referrals until there is capacity to handle them in their desired way.

‘Direct referrals largely worked well for everyone, occasionally patients would be scanned without symptoms showing up, but this was usually down to delays between referrals and scans meaning their condition had improved, rather than any inappropriate GP use of MRI capacity.

‘One upside to this process has been a substantial improvement in the dialogue between NEL LMCs and the ICB, we hope this relationship can work to improve the situation with MSK and make commissioning more responsive to the realities of local practices in other areas that need attention.’

A spokesperson for North East London ICB said: ‘The successful delivery of the MSK Single Points of Access across NEL is a significant achievement, providing patients and referrers with a simpler, more consistent route into care while improving access, streamlining referrals and supporting more efficient use of hospital trauma and orthopaedic services. The model is aligned to the principles of community-based models of care.

‘As part of this model, direct access to MSK MRI requests from primary care has been aligned with national best practice guidance, with imaging requested by specialist clinicians following clinical assessment where appropriate.

‘We always engage with the LMC and remain committed to the continued collaboration with our clinical leads in the design of services in the future.’

NHS England has recently clarified that GPs are not mandated to use A&G and will not be in breach of contract if they refer directly instead.

It comes as the CQC, GMC and HSSIB asked NHS England for ‘clarity’ on 11 areas related to A&G including a clearer articulation of A&G, GP indemnity, and patient safety implications.

Last month, Pulse revealed that one trust has moved to stop consultants refusing patient referrals from GPs by downgrading them to A&G.