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How can practices fight workload ‘dump’?

dr farah jameel 3x2

What are the latest hospital contract changes to stop work being passed on?

The most recent changes to the 2017-19 hospital contract designed to further reduce inappropriate workload on GP practices and improve patient care are as follows:

1. Hospitals must issue fit notes, covering the full period until the date by which it is anticipated that the patient will have recovered. It is a waste of GP time, and appointments, for patients to be given (for instance) an interim fit note from a hospital discharge for two weeks and to be told to see a GP for a continuation, when it was clear from the outset that they needed two months off work after major surgery – this contract change requires that the patient receives a fit note covering the full period.

2. Hospitals are responsible for responding to patient queries relating to their care; they must not ask the patient to contact their GP. This is designed to halt the culture of patients being told to ‘see your GP’ for issues that should be the responsibility of secondary care – such as hospital test results, treatment and investigations, administrative issues regarding follow-up, or delays in appointments.

3. Hospitals must not transfer management under shared care unless with prior agreement with the GP. This means GPs should not be asked to prescribe specialist medications by virtue of a hospital letter or instruction alone. Any such shared care arrangement must be explicitly agreed first by the GP based on whether they feel competent to do so, and which may include being resourced to do this as a locally commissioned service.

4. From April 2017, the changes meant hospital clinic letters had to received by the GP within 10 days. From April 2018, this maximum time limit will drop to seven days. This should reduce the impact of GP appointments being wasted because the GP has not received the relevant clinical information to manage the patient at follow-up after an outpatient appointment.

5. Hospitals must ensure they issue sufficient medication following outpatient attendance to at least meet the patient’s immediate clinical needs until their GP receives the relevant clinic letter and can prescribe accordingly. This addresses the growing phenomenon of patients turning up at a GP surgery sometimes almost immediately after a hospital appointment for an outpatient initiated prescription, with the GP pressured to prescribe without relevant clinical information, and with accompanying clinical governance risks

These build on last year’s changes to the 2016/17 hospital contract following pressure from GPC, which include:

  • Results of investigations requested by hospital clinicians should be communicated by the hospital directly to patients.
  • Hospitals should directly liaise with patients should they miss an outpatient appointment rather than ask GPs to re-refer.
  • Hospitals should make direct internal referrals to another department or clinician for a related medical problem rather than send the patient back to the GP for a new referral.

This positive change in national policy to start to address the impact of unnecessary workload shift on to GPs is something the BMA aims to continue building on.

What progress has been made so far?

It is too early to tell, but GPC is currently analysing responses to a survey we carried out in December. Anecdotally, we have had reports of some CCGs and Trusts agreeing local variations to the national contract rendering the changes less helpful than they were originally meant to be. This is undesirable.

In other areas we are aware of LMCs having negotiated a tripartite agreement between CCGs, Trusts and LMCs to ensure success.

How can GPs deal with hospitals that aren’t complying?

These changes are not recommendations but contractual requirements, and therefore if hospitals do not abide by these standards they are in breach of their contract.

However, these changes won’t simply happen by themselves overnight, as they represent changes to ingrained longstanding behaviour. Change requires hospitals to become aware of and implement these contractual changes, and for CCGs to hold providers to account. CCGs also have the ability to act on hospital breaches, including giving notice of remedial action that could include financial sanctions. Practices as members of CCGs should hold the CCG board to account to deliver on its responsibility to ensure hospitals adhere to their obligations.

Practices will be key to enabling this change, since it is GPs and GP staff who will be directly aware when these standards are not met. It is vital that we push back on inappropriate demands rather than allow them to continue unchallenged, and report breaches to both the provider and CCG.

To make this easier, we have devised practice templates for each of these contractual requirements. We encourage GPs to use them – they have been adapted to be uploaded onto clinical systems so that GPs can produce a pre-populated template letter at a keystroke.

We have also written to LMCs with template letters they can send to their local CCG and hospitals, requiring them to detail how they will ensure these contract requirements are implemented.

We would encourage GPs who are still experiencing inappropriate workload in general practice as a result of non-compliance with the hospital contract, to contact their LMCs who can escalate the matter further on their behalf.

Practice checklist for hospital contract changes:

  • Make all staff in the practice aware of these contractual requirements.
  • Develop a practice policy for how to act on breaches to these contract changes.
  • Use our practice templates for both the 2016/17 and 2017-19 hospital contract changes to report breaches to both the provider and CCG (the latter should not include patient identifiable details without patient consent).
  • Hold your CCG to account to deliver on its responsibility to ensure hospitals abide by these standards.
  • Notify your LMC of the type and numbers of breaches each month.

An investigation by Pulse found hospitals were not being sanctioned for breaching the new contract. What is being done about this?

We are currently in discussions with NHS England and have escalated the matter further. As hard-working GPs we should now be reaping the benefits of the contractual changes; we should not accept system failings that waste our time and appointments, and which take us away from meeting the core needs of our patients.

Meanwhile GPC has gone one step further and pushed for the delivery of communication pieces to enable and improve general knowledge of the changes to the interface.

In July last year, we were instrumental in creating a guidance document, jointly produced by GPC England, NHS England, NHS Improvement, NHS Clinical Commissioners, Royal College of General Practitioners, Royal College of Nursing and the Academy of Royal Medical Colleges, which describes key national requirements that clinicians and managers across the NHS need to be aware of in order to work toward improving the interface between primary and secondary care.

Through this national interface group we recently also co-produced a patient information leaflet with NHS England and the National Association for Patient Participation. The leaflet explains to patients what they can expect to happen if they are referred by their GP to see a specialist or consultant at a hospital or a community health centre. You can access this leaflet from the BMA patient information page. This is a significant step in supporting patients to navigate the interface between primary and secondary care.

What else can GPs do to push back?

Examine your workload, identify all sources of poorly remunerated or unresourced work and as a practice take an active stand together.

Review your enhanced services and look at the bottom line. A number of practices provide services that they are not being paid to provide.

Say ‘no’ to unresourced work that originates from secondary care, and where responsibility lies with secondary care, using the Quality First tools.

Dr Farah Jameel is a sessional GP in London and a member of the GPC executive team