An LMC has created template letters to help practices reject secondary care workload dumping, including rejected referrals and requests to complete work on behalf of hospital trusts.
Cambridge LMC said it developed the tools amid a growing ‘tsunami’ of secondary care workload transfer into general practices.
One template letter tackles the rejection of a referral ‘on the basis that a proforma was not enclosed or completed in full’.
It points out that the GMC requires GPs to refer when they ‘believe it is necessary to do so’ and that their ‘contractual obligations make no mention of a requirement to complete a proforma’.
It said: ‘I have provided all the necessary information required, detailing why I think it is necessary to refer our patient for your specialist opinion. This includes their past medical history, current medications and known drug allergies.’
It added that a proforma may not have been completed ‘in some circumstances’ because:
- The information was not available at the time of referral
- The information was contained within the correspondence
- The information was advised to follow at a later point, or
- It requested information that was not relevant nor appropriate
The letter said: ‘In view of the above, this referral should not have been rejected on the grounds of an incomplete or absent proforma.
‘I would politely request that you accept this referral in its current form, as a failure to do so may cause unnecessary delay or potential harm for our patient.’
A second template letter returns trust requests – such as to prescribe medication, follow up results, issue Med3 certificates, arrange investigations, undertake monitoring or refer the patient back – to the hospital itself.
It said: ‘Due to extreme workforce pressures, we are unable to undertake secondary care work for the foreseeable future, due to our need to prioritise access and primary medical care to our patients.
‘We are struggling with unsafe staffing levels and very much appreciate your collaborative approach in making every patient contact count, without overburdening other system partners across our local NHS. We shall endeavour to do the same.’
The template provides a checklist for each type of request so that practices can indicate why they are rejecting the request and what action the trust should take instead.
It added: ‘A copy of this letter has also been sent to our patient, who will be aware that you as their specialist team will now be contacting them directly to manage this request.’
Both letters are designed to be addressed to the relevant hospital consultant but copied to their trust’s medical director and the patient.
Cambridgeshire LMC chief executive Dr Katie Bramall-Stainer told Pulse that ‘we need the temperature to rise on the understanding around pressures across general practice’.
She said: ‘We appreciate that life isn’t rosy for secondary care doctors either – quite the opposite – but this isn’t a competition as to who’s got the worst pressures.’
She added that the evidence of GP pressures is ‘stark’, with her local system losing 17% of its GP partners between March 2019 and March this year, but that despite LMCs ‘working tirelessly’ to highlight this, there are often ‘few changes on the back of substantial evidence’.
She told Pulse: ‘The evidence is overwhelming and yet we still see little action. And unfortunately, there isn’t much time left to continue conversations in the hope that something will change.
‘We believe that unless you make it easier to push back than it is to undertake the workload transfer, nothing’s going to change. And until something changes, we’re going to continue to suffer workforce attrition.’
She added that the issue ‘arguably comes down to patient safety’, with the LMC being ‘copied into increasingly rancorous exchanges between consultants and practices where the patient is trapped in the middle’.
And Dr Bramall-Stainer said that it comes as the transfer of workload from secondary care has ‘got worse this year, ostensibly due to the pressures from NHS England on acute providers’ to reduce outpatient activity and ‘pursue the advice and guidance agenda’.
She told Pulse: ‘We feel that there’s been a real tsunami of workload transfer that has been driven by many factors.
‘And we keep saying repeatedly within our system, “where’s the impact assessment?”, because there’s no point turning something off in one part of the system. If you turn the tap off in one part of the system, then another part of the system will flood over.’
Dr Bramall-Stainer said that the LMC is in ‘ongoing conversations’ to have the templates adopted across her local area of Cambridge and Peterborough, but that ‘there will be a degree of nervousness’ at system level.
She added that the LMC would ‘very much encourage’ the Ardens EMIS and SystmOne tool to upload the templates to its system ‘if there’s a national ask’ and has asked the BMA to share the letters more widely too.
Accurx and PrimaryCareIT have already indicated they would ‘look into’ adding the tools to their systems.
Meanwhile, the LMC has also shared it with other LMCs across the country, with Londonwide LMCs already adapting it for use in their area.
The template letters are based on a consensus document produced by Cheshire and Merseyside ICS to tackle inappropriate transfer of work between hospitals and GPs.
READERS' COMMENTS [12]
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Yeah, but you just created more work, called a proforma. Clearly not ideal.
I have been doing this intermittently for years. It makes no difference. A new raft of F1, F2 and registrars come along with no idea of how the systems work and its is never part of their (limited) training.
I once wrote to a hospital chief executive thanking her for employing me alongside an invoice for all the dumped work. Surprisingly I never got a response and the dumping continued.
how about:
“dear colleague
please find enclosed a request from your dept.
i regret we cannot provide this med3/medication/blood tests etc (delete as appropriate) because we are under extreme pressure dealing with other, often inappropriate, work. we have advised the patient to contact you, and given them copies of your correspondence, along with your contact telephone number”
i can promise you, the one thing they absolutely HATE is joe public ringing them up !
some years ago i sent half a dozen patients straight back to the ward to collect the med3 the hospital should have given them. i also gave them a copy of tony blair (remember him ?) ‘s document stating is was the responsibility of the HOSPITAL, not the GP, to supply a med3 to cover “the expected time off work”. i told them not to leave the ward till they got it, and to threaten the staff with the press if they didn’t. all rather unpleasant – for about a week, and then the problem went away.
ok – it didn’t make me popular with the hospital doctors (most of whom didn’t even realise it was their responsibility, not ours) but i got a shedload of respect, and beer, from colleagues.
i am now retired, but still doing locums; however – i have stopped “stirring the pot” because it generated problems for the surgeries in which i work.
honestly – send out a few snottograms – it really does work !
Meanwhile when I challenged our local lmc about this recently – they told me that the hospital was having a really tough time of it and they didn’t want to pressure them too much and that they were all working jolly hard. The whole exercise is completely pointless. Burnt out, don’t care anymore, retiring early.
The LMC is good. GPs need to be clear where their responsibilities lie or we get abused from everywhere. We are not juniors that chase consultant results (it is very clear the person that orders the test is responsible) or some social worker deciding who should or should not benefit from government help. Neither are we a “bug carrier” for the police or social worker to dump social, family, child problems on. We are also not an immigration officer deciding who is legal and who is not. Stick to medicine. It is what we went in for. Should really be in the RCGP exams clarifying roles. What not to do.
Could really do with this being standardised by the LMCs and distributed by the BMA or similar, so everyone can send work back!
Junior doctor here. In my recent psych job I was told not to prescribe anything or order any outpatient investigations because the CCG wanted primary care to undertake this as that’s where the funding was directed. Now in medicine – the trust does not allow juniors to order any outpatient cardiology investigations or MRI scans – (we still have to do the out of hours work without a consultant present to request these of course) – leaving us with no option but to ask primary care to pick it up. I have no idea whether these requests are ever actioned and it would be far better if I could just order the investigations or prescribe – but the knee jerk response to inappropriate requests is always more barriers rather than educating the individual clinicians who are making the errors.
Myself and other juniors would surely welcome some uniformity rather than the current patchwork of local unofficial policies.
If you have any worrries, or concerns, about anything that is happening in your life, medical or not. Please contact your GP. If a hospital wants anything done, please demand that the GP does it. If the GP wishes to refer a patient to the hosptial, please insitute a referral management system, so that no patient can ever be referred. If you have a complaint, please ensure it is directed towards the GP.
You mean someone is trynig to reverse this decades long march to freedom. Not a chance.
My proforma would have a mandatory box for name and details of the person rejecting any referral. You know for the coroner and the courts. I want a clear and obvious line of clinical responsibility as rejecting a referral is a clinical decision with clinical consequences for real people whom we call patients.
A step in the right direction at least by the LMC. We can only hope this becomes more widespread.
The work dump is not just by the hospitals. DWP assessors calls GPs for advice and chasing follow ups or people who cannot be contacted. Never knew we had a contract to cover the DWP too. Nobody know what to do, so they call the GP. Time to reject such work dump. DWP have their own doctors.
Not sure that a patient receiving a letter explaining that procedures to help their care pathway will not be carried out by their GP will be very happy with the Tsunami of work explanation. Also remember that as a GP you are responsible for the care of your patient and that includes proper follow up of referrals to ensure that the patient is being dealt with appropriately and not batted back and forth between care providers. The Hospital will always claim that is waiting for necessary and appropriate information to allow them to proceed.Giving the excuse that your workload is too great and that you cannot provide the asked for proforma information wont wash in a court of law. Classic example. Patient referred for Barium enema for suspected Ca Patient then contacts practice 6 months later in obviously Terminal state having not received appt. Hospital did not receive letter Practice sued for failing to provide proper care and follow up of referral