Exclusive NHS England does not accept ‘arbitrary’ BMA advice for practices to redirect workload after 25 daily contacts per GP, Pulse has been told.
Under the 2023/24 GP contract, practices are contractually obliged to offer an ‘appropriate response’ to patients the first time they get in contact, and subsequent NHS England guidance said that they can only divert patients to 111 in ‘exceptional circumstances’.
Following the publication of this guidance, the BMA said GPs should redirect workload after 25 contacts in a single day. NHS England has previously declined to comment on whether exceeding these contacts constitutes ‘exceptional circumstances’.
However, in an interview with Pulse last week, national primary care director Dr Amanda Doyle said NHS England:
- finds BMA’s 25 contact limit ‘arbitrary’
- does not accept routine diversion to 111
- accepts staff sickness or unusual levels of demand as ‘exceptional’ incidences
- expects GPs to inform their ICB before redirecting patients to 111.
Pulse asked Dr Doyle whether the exceptional circumstances referred to by the commissioner included breaching the BMA’s ‘safe level of contacts’ number of 25 per day.
In response, Dr Doyle called the 25 contacts number ‘arbitrary’ and went some way towards clarifying in which circumstances GP practices could redirect patients to 111 without risking a contract breach.
She told Pulse: ‘What we have said is that we don’t want practices routinely when they are open diverting patients to 111. Part of the reason for that is that 111 is a triage and assessment service to patients go through a clinical algorithm on the phone and the outcome for half of 111 contacts is “contact your GP”.
‘But in the situation where suddenly there is an issue with the practice, people might go off sick or suddenly there’s a huge demand or something happens and they cannot deliver a same-day service in the way they would normally want to, then it’s perfectly acceptable to contact your ICB.
‘And in that specific circumstance [they can] divert patients to 111. But what we have said to practices, if you are in a position where you feel you need to divert your patients to 111, then you need to let your commissioner know. And that’s completely and utterly separate from any arbitrary number of contacts.’
Dr Doyle also clarified the now-contractual demand on practices to offer an ‘appropriate response’ to patients the first time they get in contact, by offering them an appointment or redirection, rather than asking them to call back at a different time.
She said: ‘It is not about seeing everybody first time they phone up. But what I consider to be completely unacceptable is patients hanging on the phone 45 minutes in the morning only to get through and be told they have to ring back tomorrow.
‘So we are saying our ambition is for the future – and we recognise that practices are struggling to deliver it now – but our ambition is that everyone with an urgent clinical need is assessed within the same day that they contact and routine requests for appointment are offered within two weeks.’
Dr Doyle mitigated this by saying that she knows and accepts that practices are currently struggling to fulfil that request. However, no one should ‘repeatedly’ be told to call back another day, she said.
She added: ‘I know that lots of practices have huge difficulty doing that now because demand is high and they’re struggling capacity. And I accept that. What I don’t accept is telling somebody is repeatedly trying to call to ring back tomorrow.
‘The requirements in the contract is about making it clear to someone what arrangements have been made for their care, the first time they come.’
Also in last week’s exclusive Pulse interview, Dr Doyle said NHS England is ‘not in a position’ to negotiate to a new five-year GP contract due a lack of funding commitment, with the 2024/25 contract set to be a ‘stepping stone’.
But she added that there is ‘an opportunity for longer-term reform’ of the GP contract from 2025/26, including reforms around QOF.
Pulse exclusively revealed two weeks ago that NHS England will work towards incorporating general practice in the ‘OPEL’ system pressures framework over the next year, while in the short term it expect ICSs to have tools in place to understand primary care pressures.
This would be equivalent to OPEL level 4 in hospitals – a situation when pressure means organisations are unable to deliver comprehensive care and patient safety may be compromised.
Currently, 40 LMCs led by Devon LMC are collecting GPAS data from their practices and 20 more are rolling out the system, with the first national report published at the beginning of July.
This revealed 60% of GP practices were reporting red or black alerts, indicating unsustainable pressure, while 80% reported patient contacts at roughly double the levels general practice is funded to deliver.
Dr Katie Bramall-Stainer, chair of the BMA’s GP Committee for England, said: ‘The BMA’s Safe Working Guidance was published earlier this year due to compelling evidence from GPs telling us how they were attempting to keep up with spiralling workloads.
‘Making too many patient contacts in one day is unsafe. It threatens safe patient care and can lead to professional burnout with fewer GPs working in the NHS as a result. In fact, we’ve lost the equivalent of more than 2,200 full-time, fully-qualified GPs since 2015, and a single full-time GP is now responsible for an average of 2,304 patients.
‘The BMA was compelled to issue this guidance because of the unsustainable pressures facing general practice and because, without extra funding or resource to keep up with this demand, GPs need help in keeping their heads above water and embedding measures to protect the wellbeing of their practice staff.
‘At a time when GPs are leaving the NHS in their droves, the BMA shouldn’t need to publish such guidance. Sadly, without resourcing general practice we’re not left with many alternatives to providing safe patient care. We have repeatedly said that a long-term solution is needed, and we would welcome working with NHS England and the Government to find a way to do that.’
Piffling ivory tower waffle delivered by one whose head is firmly buried in the sand and is utterly unable (or unwilling) to accept reality whilst we are drowning
Let’s address her points:
* finds BMA’s 25 contact limit ‘arbitrary’ – there is actually evidence for this. As a corollary I would be interested to know how many contacts per patient per year Ms Doyle thinks that the GMC contract reasonably funds, and so practices should provide. Based on european average costs, I would assume around 3.
* does not accept routine diversion to 111 – where should we divert them to, then? A&E?
* accepts staff sickness or unusual levels of demand as ‘exceptional’ incidences – actually the prolonged systematic defunding of general practice has made everyday exceptional in terms of demand outstripping capacity
* expects GPs to inform their ICB before redirecting patients to 111 – show us where it says this in the contract. if you can’t, you might want it but cannot compel it.
There is a simple answer to the problems in general practice, and in particular the problems with access and capacity: *fund us properly*. Move us to 11.5% of the NHS budget as we were in 2005-6, and all these problems disappear.
I see.
So 25 contacts per day is “arbitrary” but offering everyone an appointment within two weeks regardless of staffing or prevailing demand isn’t “arbitrary”.
OK……
The RCP has recommendations for the number of patients seen in a clinic. Eg Rheumatology- 6-7 new patients per clinic (30 minutes per patient) or 10-15 review patients (10-15 minutes per patient) or mix of the two.
You could reasonably argue that a specialist with an extensive knowledge and experience of a very small number of conditions has a much easier time of it than a generalist dealing with an almost infinite number of conditions.
i have to laugh don’t you?——–I’ve worked with some G.Ps who’ve had difficulty seeing only 4 patients per day
Unfortunately every day we get more and more useless rhetoric from NHS England and its mouthpieces at all levels. When will they face a reality check and pause change for a time that allows recovery of a system under severe stress.
I suspect a very tiny tiny minority. The reality is 30-40 booked appt’s and at least another 40 clinical decisions to do with patients ongoing care plus 30-40 results and 35 letters every day. Oh I nearly forgot 100+ repeat prescriptions checked and signed. But don’t worry Dr Munro we are sorting it out be retiring early working part time and emigrating. Good luck when you are poorly.
The assertion that the BMA’s limit is deemed ‘arbitrary’ raises important questions about what NHS England considers to be a reasonable and safe number of patient contacts per day per GP. As we all know, each patient interaction demands valuable time, and with time being a finite resource, it’s crucial to strike a balance that ensures optimal patient care without overburdening General Practice Service providers. Time BMA leaders specific questions to clarify what NHSE answers and tell all of us to know.
Most of the QOF targets are lets face it arbitrary.
Lets get the dialogue going – what is a reasonable number of consultations per day then ?
(once we’ve complied with all contractual, statutory and NICE guidance, read and completed the notes in plain English and dealt with the patient’s ideas beliefs and expectations)
For 6 months of the year someone is on leave, not counting sick leave etc. —ie.
exceptional circumstances at least 50% of the time .
Dr Doyle can take it up with the BMA then.
A maximum of 25 appointments a day is arbitrary, it’s sensible.
David Jenkins – just to let you know: I have reported your comment as I find it very discriminatory towards women, although I’m sure you didn’t mean it.
Shaba Nabi
Oh, for heavens sake——we all know what David Jenkins means
What a great opportunity to get NHSE to clarify what exactly is a safe number of patients per day for a GP to deal with, and when that limit is reached would they prefer us to exceed it and practice unsafe medicine. Two very simple questions.
Shaba Nabi
very sorry – let me rephrase that, for the avoidance of any doubt:
i thought the rubbish might ease off when we got rid of the last silly person in this position who tried to tell us how to do our jobs.
………..it seems not…………
does that make it easier for you to understand ?
or shall i draw a picture ?
David – may I just remind you that the current Chair of GPC England called out the sexism within the BMA when she was advised not to be a “naughty girl “ when she was about to Chair a national conference.
Words such as “naughty” and “silly” are used almost exclusively towards women and not men and they reflect the ongoing casual sexism female leaders face.
I am trying to explain this respectfully – it’s up to you if you choose to understand this.
David, also reported as offensive.
The time limit of 10 minutes per patient is also arbitrary. We should go to 20 minutes per patient per problem and can only see as many as the time allows in one session which is four hours. As far as the limit of 25 patients per day is concerned, it is evidence based. If you have not read the evidence behind it, then it is not our problem. We routinely go beyond 25 contacts per day, every day in our practice. If the service is not funded, it would not be delivered. It is as simple as that. Good will goes only so far.
Words such as “naughty” and “silly” are used almost exclusively towards women
let me get this right – you are having a go because two words in common use are used “almost exclusively”……!
key word here, i think, is “almost” !!
Gosh.
Can I say that or will someone find it offensive?
At 55 and 33 years of GP 25 (30 at a push) is my max. I cant’/won’t speed up. I won’t cut corners, I won’t do one problem consults. I will continue to pick up the pieces left by secondary care. I will continue to manage abnormal results ignored by consultants or copied to me. Patient is first. It’s the only way I sleep at night. Do the necessary. I’m mentally fucked by 6pm after 25-30 so as far as I’m concerned NHSE can fuck right off. Oh… and so can the Tories.
I should add… the day NHSE and the Tories make this approach impossible, as opposed to against their taste, is the day I retire. Looking like soon.
Dear All,
Oh so all of a sudden they don’t approve of arbitrary decisions or management. Look in your mirrors chaps.
PC
How many then Dr Doyle?
With your years on the frontline and the resources at your disposal give us a number.
So if not 111 where?
If you cant commit to this then really ditch the bunch of lanyard toting wasters you are working with and hit the frontline — you’ll love it and be truly giving back.
Appalling that the GMC and RCGP have paid so little interest over the years to working hours / intensity / staffing levels.
That included exemption from European working hours legislation up to 1998/2004/2009.
Compare that to road and rail, nuclear, maritime or aviation which have additional HSE protection.
This is less straightforward for GPs as they are not always ‘employees’.
The professional organisations who regulate/appraise/educate/ represent the profession should have been more active. Just because the attributable harm due to clinician fatigue or working conditions is harder to accurately measure doesn’t mean that it was ok to simply ignore.
Shameful. Perhaps to be expected from the GMC as they have been more interested in the political imperative of ‘controlling the profession’ and offering the worthless though symbolic A&R to the public post-Shipman.
Speaks volumes as to why General Practice can’t co-ordinate when a comments list about an absolutely pivotal issue to our profession is hijacked by perceived affrontary about an arbitrary linguistic structure possibly being in some way aligned with “casual sexism”.
Personally I would call out Amanda Doyle’s comments as “silly” were she a woman, a man, or a duck billed platypus. Except I’d be using much stronger rhetoric than silly.
Back in the land of sense, the more reality-centred have made the salient points that a> in hospital medicine, an OP list is a list and does not get added to ad infinitum – nor should we, and b> as Dr No posited in excellent vernacular, the risk to patients increases exponentially with over-burdened, burnt out and exhausted clinicians.
We, and the bodies who represent us, should be fighting tooth and nail for an agreed limit after which we are “full” and default to OOH or other services.
Dear Dr Carpe Vinum
Enjoyed your allusion to a ‘duck billed platypus and agree on that point. However, I suspect that when you are ‘full’, so is every other similar/alternate medical service.
Words such as “naughty” and “silly” are used almost exclusively towards women and not men
Not true.
Response a bit of overkill based on a false premise