A new virtual triage system in Nottingham has led to a huge increase in neurology referrals being rejected or returned to the GP with advice.
Figures obtained by The Doctor showed that 40% of referrals are now returned to the GP with requests for more information or with advice and guidance.
Before the pandemic and the introduction of the triage system only 7% of patients referred did not end up seeing a specialist, the figures show.
In April, Pulse reported that this was part of a ‘conscious decision’ at Nottingham University Hospitals to return more referrals with management advice for the GP to follow.
The figures show that in April 2022, 272 of 454 referrals were accepted by the neurology team with 182 returning to the referrer with advice, more information needed or to redirect the patient to another service.
Between December 2019 and March 2020, between 7% and 11% of patients were sent back to the GP with a big jump to 35% as the pandemic hit in April 2020.
For one six-month period, more than half of referrals were rejected or advice and guidance given, the data shows.
Information sent to GPs and seen by Pulse said: ‘Neurology has made a conscious decision to carefully vet all referrals from primary and secondary care.
‘You will have noticed a much higher proportion of neurology referrals now get returned with advice. Please be assured the sole driver for this is patient care and safety.’
The statement said capacity was not available purely to relieve patient anxiety.
Yet the figures show the number of referrals being made now – around 400 on average a month in 2022 – is less than before the pandemic started when more than 600 patients a month were being sent for a specialist consult.
GPs and LMC leaders told Pulse back in April the change had happened by stealth and they had concerns about the shift of risk and responsibility for patients back to primary care.
Nottingham GP Dr Irfan Malik told The Doctor: ‘We only refer when we absolutely have to, but more and more referrals are being rejected with advice and patients not seen.
‘Every referral is becoming a battle and a struggle – they send a letter back with lots of advice and things to do and other referrals to make. The patients are getting stuck and they still have the problems they initially had.’
Michael Wright, chief executive of Nottinghamshire local medical committee, said a number of local GPs had raised concerns that the increased use of advice and guidance was ‘effectively a way to control workload rather than address genuine clinical need’.
‘This also causes practices extra work and GPs would feel that they’ve discharged their contractual duties responsibly by referring the patient and would prefer to use A&G when looking for pre-referral help as the name suggests – advice and guidance.’
‘The CCG (now ICB of course) feel that this is a planned change which is not a deflection of patient referral. That it is a legitimate and appropriate way of delivering healthcare in a pressured system.
‘It is coming up on the agenda of the local Health and Scrutiny Committee. It is also felt that greater use of A&G is likely to be nationally directed.’
Dr Keith Girling, medical director at Nottingham University Hospitals NHS Trust, said: ‘Following national guidance, our Neurology Service adopted a virtual triage system for outpatient referrals during the Covid-19 pandemic. The aim was to deal with both the challenges that the pandemic brought, as well as to meet the needs of patients who we could actively help and care for. We continually strive to improve our service for our patients.’
Dr James Hopkinson, joint chair and clinical lead at NHS Nottingham and Nottinghamshire CCG, added: ‘We continue to work with all elective services in Nottingham University Hospitals Trust, and we are trialling different approaches including using technology for remote consultations and increased use of advice and guidance.’
Nottingham City Council’s health and adult social care scrutiny committee will today discuss concerns over the neurology service with the trust’s medical director and head of neurology service at its monthly meeting.
Documents published ahead of the meeting revealed that the committee chair wrote to the trust in November last year regarding ‘concerns’ raised about ‘referrals from GPs being turned down and patients therefore potentially being unable to access the [neurology] service’.
A committee paper said: ‘The Committee has recently been contacted again about continuing concerns about referrals and therefore decided to invite the Trust to the meeting to discuss access to the service.’
Concerns over neurology referrals in Nottingham
The November letter said the committee had been contacted by ‘a number’ of ‘increasingly’ concerned residents and GPs regarding ‘access’ to the department and requested data on accepted and rejected referrals over the past five years.
Responding to the letter in January, the trust said that the ‘demands’ on the neurology department are ‘formidable’ and that the service had faced ‘challenges even before the pandemic’.
It added that the department receives ‘over 150’ outpatient referrals a week but that it is ‘able to offer in the region of 60-70 appointments per week’.
The trust’s letter said: ‘Whilst it is certainly true that all patients are deserving of having their case evaluated, with a proper history and examination, there are some symptoms for which further investigation is not necessary, and others where there are very clear, pre-referral management steps that can and should be undertaken in primary care (simple blood tests, lifestyle measures, initial therapy where this is supported by NICE guidance, monitoring and reassurance).
‘The aim of these guidelines is not to obstruct the path to a neurologist, but it is to recognise that when Neurologists see patients with such complaints they follow almost to the letter the guidance enshrined in such documents. ‘
It added that the trust has implemented a system where referrals are triaged by consultant neurologists to ‘maximise the “added value” that neurologists can provide’.
It said: ‘If they feel that there are simple management steps that can be undertaken first in primary care, or the referral is otherwise unsuitable for the neurology outpatient clinic, they will respond to the GP with a bespoke letter explaining the reasons, and outlining their recommendations.
‘We have not made any changes in our service lightly, but have made these changes recognising that we must focus our collective expertise where it is really needed.’
The letter stressed that the trust is ‘not deviating from’ NICE guidance but is ‘now applying these guidelines correctly, when historically we may not have’ – and that ‘senior colleagues in general practice’ have been ‘very supportive of our approach’.
An update submitted by the trust ahead of today’s meeting added: ‘It was quite clear that neurology outpatient appointments were not being used as productively as they could be.’
It claimed that there are ‘very few referrals that are “rejected” outright’ and said that an ongoing audit of its ‘vetting process’ has so far ‘not identified any safety issues’.
However, it admitted that its audit showed that ‘on occasion we should have made an onward referral to other services within NUH’ and said the trust is ‘already working to improve that process’.
It added: ‘The alternative (a model run by most NUH departments, and most neurology departments) was to simply run up a vast waiting list and a legacy backlog of patients.’
READERS' COMMENTS [9]
Please note, only GPs are permitted to add comments to articles
In Northern Ireland in my patch, routine neurology referrals are taking 7 years on average and urgent referrals are now sitting at 5 years delay
So effectively, we have no service for neurology gp referrals here, so if I could even get an opinion and guidance from a neurologist it would be so much better than we currently have here…
This is beyond offensive. GPs are not neurologists SHOs to take orders from them to get more information or to perform tests on their behalf. It does not matter if the purpose was for patient care primary care is in crisis and cannot take on more burden. It is clearly not for patient safety. Patient safety is best served by increasing availability of secondary care to meet need/ demand.
This is purely to save money.
If 40% of referrals are rejected there is a disconnect between the GP threshold for what is their job and secondary care opinion of what their job is.
Given this is a change from the norm there should be a transfer of funding.
If it is ‘easy’ for GPs to sort this out and the issue is a lack of neurologist perhaps the neurology department could employ a GP, or Physician Associate, Specialist Nurse etc to do the initial work.
That they don’t, and that the commissioners support this, shows it is a financial dump.
182 referrals rejected * c£180 = £32,400 / month = £388,000 / year.
Presumably that money has all been seemingly passed back to the GPs…. (!)
I would agree the biggest issue here needs to be to align Consultants’ view of what a GP can do confidently, and what a GP actualy can. Unfortunately,m whilst most GPs have worked in hospitals, and most of them done jobs in or birdering on Neurology : How Many Neurologists have spent 6 months in a GP Practice in UK, or even at all ?
It may be that there is a short-staffing in Neurology services (I think there IS), but the action from that should be for Neurologists to highlight the shortage, and institute the training of more Neuroligists, not sit back and wait for GPs to accept the work.
Having said that, quite often the referral system is not flexible enough to GPs just seeking advice or needing approval for something outside what we are allowed or supposed to do.
But it is about time secondary care specialists became more adept at using remote consulting (the consultants, not the nurse specialists!) and willing to take responsibility for decisions over the phone or video link, in a time-limited consultation, instead of spending an hour with a patient and then asking GP to take responsibility for decisions and prescribing. I GPs have to do this, then Consultants with their presumed greater skills and more extensive specialist training, should be able to do it easliy.
GPs are already screening out most non-urgent things, and since covid, have been more thoroughly doing so, as well as some patients really not wanting to go anywhere near a hospital if they can avoid it. Referrals are down, the waiting times need to be tackled now, before it gets worse.
Just like Neurology virtual triage, this virtual triage should be extended across the board to all medical specialities. This will help in reducing referral waiting times and improve interdisciplinary interaction and overall improvement resulting in delivering a better and safer quality Health Care to the patients.
There are many reasons GPs refer to specialists.
One of the reasons is that we have, on average, three problems to manage in ten minutes; whereas a consultant will get 20-30 minutes to manage a single problem.
If I also had 20-30 minutes per single problem, I could look up the NICE guidelines on problems I encounter rarely, and deliver the care. In fact, most GPs could probably deliver 80% of outpatients, if we all had 20-30 minutes per single problem and didn’t have to manage the patient holistically.
The reason we have specialists is because it is much more efficient to train a subset of doctors to be specialists in order to be able to manage a small group of patients who need extra input more effectively and efficiently.
Redesigning the system this way is based on the misconception that consultants are only there as a last resort for fiendishly complex cases.
It is interesting to note that consultant numbers have matched increases in workload in the last ten years and exceeded population growth – whereas GP numbers have actually shrank considerably, and lag around 30% below where they should be.
As for the reasons given for the change – they are all straightforward lies. If neurology are seeing 40% fewer patients, then the service should be defunded by 40% and the full amount put into general practice to fund this A and G nonsense.
The patient wants.
The patient gets.
Change your culture and you may change the referral process.
Until then – the public are being misled and mi-sold promises of infinite freebies and now being fobbed off – NOT by General Practice – by the impenetrable trusts. The secret is out.
As Simon says – sort out the perverse Tariff culture too – and pay GPs for a follow-up. Otherwise, free follow-up without tariff, and pointless going around the circles with little GP respect for what you already know is a meaningless task and who would want to do that? Refer it.