Trusts in various parts of England are making ‘conscious decisions’ to send more neurology referrals back to GPs to manage, Pulse has found out.
Pulse understands that a national shortage of consultant neurologists is leading to several areas having to restrict or ‘vet’ referrals from GPs, with the cases being sent back to primary care.
One trust put out a statement saying that this was being done because of ‘patient care and safety’, as referrals were taking over six months to be seen.
GPs have said that this amounts to introducing advice and guidance ‘by stealth’ – under A&G services, GPs access specialist advice by telephone or IT platforms rather than referring patients for a hospital investigation.
Pulse has learnt that a trust in Nottingham has made a ‘conscious decision’ to return more referrals with advice, while one in Kent has had to temporarily stop accepting neurology referrals due to increased staff absences.
The statement by Nottingham University Hospitals, shared by GPs on Twitter, 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.’
Without the new system in place, referral waits would be over six months and patients would not be seen ‘in a timely manner’, it added.
It said: ‘Whilst it is recognised that a formal neurology review will always help reassure patients, the capacity is not available to arrange reviews purely to relieve anxiety anymore and this is unlikely to change for the foreseeable future.’
Local GPs said there were particular concerns over neurological symptoms which is an area they have little knowledge of.
Dr Irfan Malik, a GP in Nottingham said: ‘We have been struggling with neurology referrals for several months with advice given or rejected. Then last week the neuro team put out a statement. This was the first official response we had seen.’
He added that it was A&G by default and warned that GPs could be held responsible if patients fall through the cracks.
He said: ‘We are not very happy about their explanations. There is also the risk element of a missed diagnosis after neuro advice or rejection – will the specialist carry the can? Or will they blame the GP?’
Nottinghamshire LMC treasurer Dr Jen Moss Langfield said that local GPs were supportive of their secondary care colleagues, but added they ‘weren’t informed about this in advance’.
She added: ‘It’s a move to referrals via advice and guidance by stealth. There are questions around safety and moving the responsibility and risk into general practice.’
She added that GPs would only refer when they really needed to and some patients may have diagnoses that end up being missed, especially those with subtler symptoms.
Dr Jonathan Evans, consultant neurologist at Nottingham University Hospitals, said the issue was not principally about capacity but ‘about recognising what a secondary and tertiary referral service is for, where the added value of a neurologist comes, and streamlining our services to be able to deliver this as promptly as we are able.’
He added that his colleagues would be happy to respond to any feedback from GPs about the approach.
Meanwhile, in Medway and Swale in Kent, routine neurology referrals have been suspended until further notice ‘due to unforeseen issues’, with GPs provided with an advice and guidance (A&G) route for non-urgent cases.
Chief executive at Medway NHS Foundation Trust Dr George Findlay said: ‘Due to increased staff absence, routine neurology referrals are temporarily managed by other hospitals in Kent through the Neurology Assessment Service (NAS).
‘There is also a dedicated consultant-led hotline which allows GPs and hospital colleagues to access expert medical advice for patients with neurology conditions.’
Figures from the Royal College of Physicians for 2020/21 show that 51% of consultant neurologists in England report having locums filling staff vacancies and 38% reported unsuccessfully trying to appoint a consultant post in the past two years.
Earlier this month, Pulse reported an MDO warning that GPs could be held liable for advice given to them by hospital colleagues about their patients via ‘advice and guidance’ services.
Under NHS England plans, increases in elective activity by 10% over the next year will predominantly be achieved through increased GP advice and guidance.
READERS' COMMENTS [8]
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My daughter was referred to see an ophthalomologist for persistent red eyes. The ophthalomologist prescribed eye drops for dry eyes following a phone consultation. The GP is refusing to prescribe this eye drops saying the hospital has to prescribe. This is a silly excuse. I can’t argue with the GP as I have to be do the ‘E Consult’ and then triaged by reception staff and then the GP again refuses to prscribe the ophthalomologist advised eyes drops.
This seems to be the current GP trend among most GP surgeries.
Let’s be realistic
Access to both GPs and specialists are going downhill and will only worsen .
While I can see the argument about defining ‘appropriate’ referrals from primary to secondary care, this matter is always complicated . We are never in the ideal world, it is indeed about capacity of GPs and specialists right now despite how one repackaged the argument.
By all means A&G is a form of compromise . I would see that as a similar argument for expanding GP telephone triaging . On the contrary , the genuine bottom line question is ‘ when is A&G inappropriate and unsafe ?’
I can see the caveat of ‘lost in translation’ when the practice is universally adopted . Once the pendulum is swung to an extreme , we will have to ‘embrace’ the consequences .
Looks like the PCN model is working in your favour – isn’t it?
Also – it has to be said, some GPs can’t even string together some intelligent words in a referral letter, and they deserve to be rejected. If all you are writing is “Please see attached” via your receptionist, then that is plain lazy and asks no question. I would reject any receptionist referring to me.
If this is a game – you need to know the rules.
Take a referral for recurrent disabling migraine sufficient to warrant preventative treatment which you are unhappy to initiate a prescription for eg selegiline.
Construct referral :
Is the diagnosis correct ? Differential diagnoses – including TIA’s / epilepsy that need to be excluded.
Investigations that are likely to be needed to explore/exclude a diagnosis : X-rays/MRI/EEG/ CT/PECT scan.
Medications : review of those already tried, others to be considered , severity and effects on lifestyle sufficient to warrant preventative therapy , monitoring required for these, and effects on driving etc etc. Planned review to consider benefits and consider alternatives if necessary.
Medico-legal implications of confirmed diagnosis and necessary explanation to patient of these implications .
Possibility of a second opinion already raised by patient if they have alredy lost trust in you and may be suspicious of your choice of specialist you have reffered patient to.
Couched in the above format I think it would make responding to such a referral with advice and guidance difficult and medico-legally fraught on behalf of the Neurology Dept / Consultant . There are just too many variables and uncertainties that have been raised for a coherent A&G response.
You may disagree – I did retire nearly 9 years ago.
Investigations
“will the specialist carry the can? Or will they blame the GP?’”
this is a complete no brainer – you can’t blame the specialist, because they haven’t seen them !
it’s obviously the GP’s fault – like brexit, war in syria, ukraine, global warming, energy prices, P&O ferries, etc etc etc……………..
i would encourage the patient to contact the hospital – give them the secretary’s number if you like. they will then understand where the delay is – instead of continually coming back to us and thinking it is us who are fobbing them off.
Secondary care declines work but still wants paying shock.
The purpose of specialist care was quoted to me by a patient this week.
‘To know more and more about less and less’
to be funded more and more to do less and less could be an unfair paraphrase.
Though as overall activity in 2ry care is significantly down, and funding is significantly up…
Still neurologists have always competed with neurosurgeons to live closest to the stereotypical ‘what actually are they for’.
If they are not for opinions on patients then …?
(note there are probably a few who are being let down by the ‘bad apples’ )
red eyes and who to prescribe.
no one size fits all here and all 3 parties frustrated
. Is there a reason why the Ophthalmologist did not prescribe at the end of the consultation
if say the script was for steroid drops and pt not seen who then is legally responsible?
who is arranging follow up if the treatment does not work and when?
Yes I agree the barriers are up in many GP surgeries who spend endless hours trying to get secondary care, at the same time as the NHS bosses seem to spend even more time trying to stop secondary care work
Many in primary care think there is a master plan to destroy the idea of an independent Gp and also cold surgery for hips eyes etc just a a they have very nearly done already for dentistry
I was referred in December for new onset epilepsy. By mid January I had heard nothing. After a convoluted series of phone calls I was told the appointment would be June at the earliest. My GP emailed a further request and I had a telephone consultation soon after. Meanwhile I had another seizure. The consultant said he would review me in 2 months. The appointment is in November!