A new triage system introduced for neurology referrals in Nottingham is likely to have had ‘minimal impact’ on GP workload, the head of the department told the local Health and Scrutiny Committee today.
Speaking about changes which have led to a report by The Doctor that 40% of referrals being returned with advice and guidance, consultant neurologist Dr Jonathan Evans said recommendations made to the GP may be around trialling a new medicine which is similar to what would happen when seeing someone in an outpatient clinic.
But he added the department had accepted they needed to do more to facilitate referrals to other services rather than ask the GP to do it and they were putting in systems to address that.
The committee heard that some GPs had raised concerns about the changes, where neurologists had started to ‘vet’ all referrals and had said a proper consultation with primary care had not been done before they were introduced.
Data presented to the committee said 57% of those returned to the GP had a bespoke advice and guidance letter. Another 17% were patients who probably should and would be seen but more information was needed to decide what clinic they needed.
In all, one in five needed to be seen by another department and ‘we acknowledge we could do more to activate that referral ourselves and we’re doing that’, Dr Evans said.
He told the committee the changes were in line with NICE guidance and meant that patients who really did need to be seen could get an appointment in 16 weeks rather than waiting a year or more as happened in other areas of the country.
While the changes were not solely about capacity, the department is short-staffed he said with only 15 consultants serving Nottingham and surrounding counties including Leicestershire and Lincolnshire compared with Sheffield for example who had 30 consultants.
They are putting together a business case for more staff but also different pathways for example in how patients requiring a neurologist are seen after emergency admission.
He said: ‘We find making a recommendation to trial a medication may not substantially increase the GP workload over and above what would happen if they were seen in clinic,’ he said but that it meant patients did not have to wait as long.
‘It’s not for me to manage the workload of GPs, I have patients telling me it’s easier to see a neurologist than it is to see a general practitioner, read into that what you will.
He added: ‘Decisions are being made that impact on GP workload. I’m not sure I’m in a position to dictate how they should be spending their time. All can say is that the additional work from what we are doing in this triage is in my view minimal.’
It was acknowledged at the meeting – also attended by Dr Keith Girling, medical director at Nottingham University Hospitals NHS Trust and Dr Stephen Shortt representing the ICS – that while signed off in principle by the CCG, the amount of consultation and communication done with local GPs had been insufficient.
Councillor Georgia Power, chair of the health and adult social care scrutiny committee at Nottingham City Council, recommended that more was done to consult with primary care and patients when changes of this size were made and called for as much support as possible for system working.
In response to a question about taking responsibility if a patient is sent back to a GP then was later discovered to have an issue which should have been seen by a specialist, Dr Evans said: ‘Effectively when we are returning a referral with advice and guidance, assuming that’s what happened rather than a request for more information, we are passing responsibility back to the GP.’
He added that should a patient re-present to the GP they could make another referral but their audit data showed them those instances were few and far between.
Dr Irfan Malik, a GP in Nottingham who had raised concerns about the changes, told Pulse that returned referrals with ‘advice’ was creating a significant amount of work.
‘We have letters with up to seven action points for us to complete with the patient, sometimes involving referral to another speciality.
‘My patients that were not seen have subsequently paid to get a private neurological opinion. These patients wouldn’t appear in their audits of patients returning to them.’
He added: ‘The neurology department clearly has poor insight into the impact of the enhanced vetting policy on primary Care, which has resulted in up to 50% of referrals returned with advice.
‘The drastic change in GP referral management has been poorly communicated to GPs and patients leading to the City Council Health Scrutiny Committee being involved.’
‘Unfortunately, we don’t have the capacity to mop up the extra work generated from neurology outpatients.’
The plans were first revealed in draft guidance seen by Pulse in February, which set out that GP A&G ‘could contribute an estimated six percentage points’ towards the target of ‘over 10% more’ activity.