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Trust increasing GP workload with inappropriate A&E attendance reports

GP practices being told off for patients inappropriately attending A&E

Exclusive GP practices are being asked to review incidents of patients inappropriately attending A&E, even when this was signposted by 111, Pulse has learned.

East Suffolk & North Essex NHS Foundation Trust (ESNEFT) A&E sent reports through Datix, an electronic incident reporting system, to GP practices in response to ‘inappropriate attendances’.

Local GP leaders said these reports appear to encompass anything the A&E consultants feel inappropriate for them, including 111 reports and patients being care navigated.

The LMC said this was in the context of practices having some of the ‘lowest A&E attendance rates on record’.

A Suffolk LMC newsletter said: ‘Practices in the East will be aware that Datix reports are being sent from ESNEFT A&E in relation to inappropriate attendances. This is the context of those practices achieving some of the lowest A&E attendance rates on record.

‘The LMC continues to engage with the trust on this and would advise practices not to take any further action in relation to Datix reports received in this context.’

One report sent to a Suffolk GP practice, seen by Pulse, details an ‘incident’ where a patient ended up in A&E after 111 called an ambulance.

The report said: ‘As the incident involves your organisation, we invite you to provide us with a response that can be fed back to the area where the incident occurred.’

The report added that it is ‘standard practice’ within the Trust to ‘take every opportunity to explore all incidents’ to ensure ‘any learning results in improvement to our services for patients, and supports our staff in delivering those services’.

‘We trust you will therefore be able to provide us with a response that supports this,’ the report said.

Suffolk LMC chairman Dr Richard West told Pulse the Datix reports are ‘a sledgehammer to crack a nut’.

He said: ‘It’s actually the unintended consequences that makes the situation worse, because you’re pulling clinicians away from clinical work in order to deal with administrative things, when actually, there’s very little we can do about this.

‘We understand the frustrations that [ESNEFT A&E] have, and share to a certain extent, the frustrations that they have, and if we all had more workforce and capacity, none of this would be a problem.’

He added: ‘The hospitals feel frustrated that actually [the patients] shouldn’t be here, and they could have used something else. It’s very much a symptom of the problem that we’ve created a view that I can see now and when I want to be seen, and therefore when that doesn’t happen… they then aim for somewhere that they can, and A&E is one of those places.

‘111 does have a tendency to play things as safely as possible and therefore will push patients up a stage and escalate rather than deescalate.’

Dr West told Pulse that the number of Datix reports is ‘significant enough that the community of general practice is talking about it, and it’s causing stress and concern’.

Suffolk LMC medical director Dr Peter Smye said the reporting ‘appears to encompass anything that the A&E consultants feel inappropriate for them’.

That includes 111 reports, which Dr Smye is ‘fairly rare, but completely outside the GP’s control’, as well as patients being care navigated.

He added that the reports are ‘a major source of strife locally which the LMC has repeatedly sought to defuse’.

The BMA and RCGP said all health professionals working in secondary care should spend ‘at least’ a year working in general practice as part of their training.

Another LMC created a template letter for GPs to send patients to A&E when they are ‘unable to get through’ to a specialist.

Last year, the RCGP disputed the health secretary’s suggestion that people are turning up at A&E because they cannot reach their GP.

READERS' COMMENTS [16]

Darren Tymens 17 May, 2022 9:59 am

It’s not in your core contract, and it’s not incentivised, so there is neither carrot nor stick to enforce this.
The LMC just needs to circulate a letter informing practices that they can engage – if they have lots of free time and spare capacity – but there is nothing in the contract that compels them to. Perhaps a standardised email response would be helpful. If the ICS is interested in auditing this, they should consider funding practices to do it, on an entirely voluntary basis.
What our consultant colleagues don’t seem to understand is how high-pressured our job is, and that there isn’t time and mental space to do extra things. The equivalent would be to expect them to perform a similar full audit – but outside of their scheduled hours, in their own free time.

Neil Tallant 17 May, 2022 10:12 am

All this was done 15+ yrs ago. Meeting after meeting, endless reports on what A&E considered to be “Inappropriate” attendances , all with the expectation that we, GPs , will stop it happening. Oddly, despite various initiatives and plans nothing happened and clearly nothing worked. Rather than GPs spending yet more time re-inventing the wheel of no return, perhaps just return the reports as inappropriate correspondence?

Joanna Rudnicka 17 May, 2022 10:17 am

Sadly inappropriate GP referrals to A&E happen quite often in our DGH and most of us are too busy seeing Patients to submit Datix reports. I believe that better communication and “reminding” some GP’s what not to refer is the key.

Simon Gilbert 17 May, 2022 10:26 am

An a/e consultant should stand silently at the reception when the patient checks in and, based on that, intervene to send the patients home, before they write the datix.

Triage is not consultation and ‘inappropriate attendance’ cannot be a retrospective diagnosis after further assessment. Our NHS system seems to have no concept of risk and probability with regards to high stakes but lower probability diagnoses such as atypical presentations of MIs or PEs.

A system of organising healthcare that cannot draw in resources to where the activity occurs, but instead allocates resources by shaming and bureaucratic pressure, is a poor system in a developed economy in 2022.

Simon Ruffle 17 May, 2022 11:13 am

Many thanks for your note and for the inappropriate X- Ray and blood results that we are unable to access and review acutely as we are not funded to be an acute unit.

paul cundy 17 May, 2022 11:42 am

Dear All,
Oh and there’s the small issue that patients know how to manipulate the system. I’ve worked in OOH, GP and A/E. I’ve had a nurse re-director ring me in my surgery complaining that a chap in her A?E was there because he couldn’t see us. luckily I was able to point out he was actually there because the appt for later that day we had offered him was not convenient for him.
Patients tell us one thing, NHS111 another and A/E yet more. They know how to manipulate the system. As long as NHS111 over react and A/E see anything por anyone who turns up they will continue to capitalise. One of the problems is the 4hr target. Why book a GP appt if you know you will be guaranteed to have your 3 month old itchy bottom sorted in 4 hrs? The sooner A/E start to triage and make non urgent patient wait until the serious stuff has been sorted the better.
Regards
Paul C

Samuel Liddle 17 May, 2022 11:49 am

OK. In return I’ll report every single patient I’ve seen that should have gone to A&E; minor injuries, chest pains, falls, cuts, scrapes, abrasions, swollen legs… the list goes on.

It’s tit for tat. We see stuff that really should have gone to A&E. They see stuff that really should have gone to GP.

Patrufini Duffy 17 May, 2022 3:18 pm

I heard of a patient who wasted two AE attendances in 2 days at different Trusts. Then 111. Then 3 GP appointments. In the space of 2 weeks. She fitted in a holiday in between. Funny that. And has been categorically told she has anxiety and panic attacks. Instead, she has had 2 sets of bloods, abdominal ultrasounds, pushed for an ENT referral and got it, and had 2 sets of trial of medicine and says “I’m not a hypochondriac”. Yes you are, and the system isn’t letting us tell you that. It’s a dead end, literally. The UK is generating US medicalisation, it is business, so go with it.

Vinci Ho 17 May, 2022 3:28 pm

Ok , some points in here :
(1) If we want to go down this road of tit for tat between GPs and consultants i.e. primary vs secondary care , it is fine .
Then I would want to ask how many inappropriate referrals( requiring time consuming actions) referred back to GPs from consultants ? How many GP referrals were rejected inappropriately and in certain cases , arguably dangerously ?
(2) The reality is specialties including general practice , psychiatry and indeed accident and emergency, are dangerously( in my opinion)short of workforce , time , space and essentially expertise. Experienced clinical colleagues( including paramedics and senior nurses) at the frontline are all fed up and leaving or cutting down their working hours . If choices are available, these experienced colleagues will take early retirement sooner than later . Of course , many also crashed out because of illnesses with or without burnout syndrome.
(3) By all means , triaging , whether at GP or A/E level , remains a sensible mechanism for moving forward in 21st century NHS .
But even triaging needs prerequisites including time , expertise and manpower/workforce . NHS111 is exactly doing triaging without these essential ingredients and the end result is so called inappropriate or even ridiculous referrals . In the eyes of some , it is not only unsafe but could be interpreted as ignorant and even reckless depending on the circumstances of each individual case .
(4) While I can understand where A/E consultants ( they are sufferers themselves crying out for help )came from with this label of ‘inappropriate attendances’ (and we can certainly retaliate with what I wrote above in(1) ), the bridge between primary and secondary had already been burnt away by all these government quangos (through reforms after reforms and of course , Command and Control ) . Whether we are talking about NHSE/I , ICS(CCGs disappearing end of June this year ) , ICB , and DHSC at the top , they all failed to find peace and harmony between GPs and Consultants, for instance . Instead with ignorance , political correctness and loss of touch with frontline reality , they inadvertently(if one is still sympathetic to use this word) poured gasoline into fire driving a big wedge , widening further the huge gap between primary and secondary care . Animosity, distrust and rejection become the recipe of a war between these two vital sectors of NHS .
(5)The system is truly broken now with no leaders high up in the hierarchy to admit their mistakes (one after another) with honesty and humility . Mr Health secretary , what are you actually doing every day , while your Prime Minister is obsessed to become the 21st century Winston Churchill fighting inevitably a Third World War ?
So collectively(all of us in the frontline), who is our common enemy ? I think the answer is too obvious for me to write any more words .

Balaji Chalapathy 17 May, 2022 3:32 pm

Has anyone thought of doing a report to hospital on why our patientshad to wait more than 12 hours in a&e or why they are not meeting the outpatient target. Ask them to explain their actions

Kevlar Cardie 17 May, 2022 3:42 pm

A clumsy move taken from page one of the Nick Machiavelli “Big boys first book of NHS managerial dirty tricks” .

Set one set of clinicians against another, then stand well back.

Vinci Ho 17 May, 2022 3:43 pm

And Mr Health Secretary,
This is a quote from the last season of Game of Thrones (Jaimie, sorry , you probably won’t totally get it ) :

Jon Snow, ”But when enough people make false promises , words stop meaning anything. Then there are no more answer but better and better lies. And lies won’t help us in this fight.”
Tyrion Lannister,”That is indeed a problem. The more immediate problem is that we’re fu*ked”🤨😈

Vinci Ho 17 May, 2022 3:47 pm

And for those who are too hot-headed :
Peace always starts by acknowledging reality
The Economist 29/5/2021

Samir Shah 17 May, 2022 5:19 pm

Well said Vinci (and Tyrion Lannister).

Arun Perumpallil 18 May, 2022 6:49 am

Lots of patients I see have self limiting conditions that improve spontaneously. Do we call those attendances inappropriate? As a reader pointed out calling an attendance inappropriate after a full examination, blood tests and radiology is not ideal. If patients prefer to be seen in A&E is it not better to stop these arguments and augment the staffing in A&E. There need to be a safe limit to the number of patients a clinician can safely assess in a 4 hour clinic in any setting and there is hardly ever an unfilled GP appointment. Finding practical solutions should be the way forward than finding fault within tiers of the same system.

David Jarvis 18 May, 2022 6:40 pm

Well I generally would ignore these letters. Not get angry or irate. Do I have any power or control to change this. Nope. So is there any action to take? Nope. If sending pointless communications makes them feel better in an overstressed A&E then dig yourselves out. We have complained to ambulance services about failures and nothing happens. You can complain about patients registered at my practice making bad service choice. Nothing will happen because I can’t do sod all about it and will thus give it an appropriate amount of attention. None.