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GP ‘black alert’ guidance suggests cap of 25-35 routine consultations a day

GP practices facing an unsustainable workload should divert or cancel all routine appointments, under a new ‘black alert’ system proposed by the BMA.

The BMA, which voted in favour of GP practice black alerts last year, has established four ‘operational pressures escalation levels’ similar to the system used in hospitals.

Whether a practice can take the action unilaterally, without prior approval, is currently unclear.

The BMA guidance, prepared by the GP Committee, suggests that 25 routine appointments a day are a ‘safe’ limit for individual GPs, with 35 deemed as ‘unsafe’. For more complex consultations, the number is lower.

After this, the practice should ‘divert patients to other clinicians or alternative providers or later sessions/days’.

If all GPs in a practice are working at unsafe levels, a locality hub should take on its ‘overspill’ patients.

Meanwhile, if all practices in the same locality are reporting unsafe working levels, all routine long-term conditions clinics should be cancelled, and hospitals told ‘discharge management will be suspended until primary care recovers’.

This comes as a Pulse survey revealed that GPs in the UK have an average of 41.5 patient contacts every day – 60% more than the number considered safe by European GPs.

The guidance says that ‘appropriate limits on workload will depend on the unique circumstances of each practice and the preferences of each individual GP, as well as the complexity of care being provided’.

The BMA suggests therefore ‘a range in the number of appointments per day to show when a GP may move into more “unsafe” practice (red), depending on whether the appointments are routine or complex’.

The guidance says: ‘For example, up to 25 routine doctor-patient contacts a day could be deemed ‘safe’, with GPs only reaching “unsafe” working levels at 35 or more routine patient contacts per day.

‘In comparison, anything over 15 doctor-patient contacts for long-term, complex or mental health conditions could be said to be “unsafe” due to the more demanding nature of the consultations.’

The BMA said that the system ‘will only succeed within a locality where a range of safe working levels has been discussed and agreed, and where practices are assured that all other providers are operating above agreed minimum quality and capacity measures’.

It added that ‘such a system will need peer-controlled audit and free exchange of information’.

GPC chair Dr Richard Vautrey said the guidance meant ‘working within the existing contractual mechanisms to be able to deliver a safe and sustainable service’.

He said: ‘It’s in everybody’s interest whether that’s the local CCG, NHS England or general practice, to have a sustainable safe service. We would hope that local commissioners will work with practices to enable that to happen…

‘No right-minded thinking person would want their patients to be seen by tired, exhausted doctors.’

Dr Vautrey said the black alert system was necessary as GP workloads ‘increasingly unmanageable’ owing to ‘the demand of more complex patient needs, widespread recruitment and retention issues, and years of underinvestment – all of which takes a toll on GPs’ physical, mental and social health’.

The proposal of capping appointments and diverting to overflow hubs formed part of the GPC’s Urgent Prescription for General Practice published two years ago, and the BMA’s Annual Representative Meeting voted in favour of GP black alerts last June.

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An NHS England spokesperson said: ‘While arbitrary caps on patient appointments would breach GPs’ contracts, we understand the pressures general practice is facing. That’s why the NHS is investing £2.4 bn extra in GP services, growing the number of new doctors entering general practice, and rolling out evening and weekend appointments to patients across England over this coming year.’

The operational pressures escalation levels’ (OPEL) alert system

Level 1

Individual GPs or other clinicians are at or above the locally agreed safe level of working.

Action: Internal practice action to divert patients to other clinicians or alternative providers or later sessions/days. Notify position to Locality Hub.

Level 2

One practice reaches unsafe working levels.

Action: Practice reports status to Locality Hub. Hub initiates improved triage and allows practice access to booked overspill appointments.

Level 3

Several locality practices reach unsafe working levels

Action: Hub initiates improved or centralised triage and releases all overspill appointments. Other practices and Hub clinics are alerted to potential “Black Alert” status.

Level 4

All practices in the locality report unsafe working.

Action: Locality Hub switches available workforce to address overspill (Triaged and booked appointments) thereby cancelling routine LTC and specialist clinics. Locality alerts Hospital that discharge management will be suspended until primary care recovers. Planned early discharges are therefore temporarily stopped.

Source: BMA