One of our partners has been rude and aggressive to consultants verbally and in writing over perceived workload ‘dumping’. How should we proceed?
Dr Grant Ingrams: Be aware that consultants are not always to blame
Workload ‘dumping’ – the inappropriate passing of work from secondary to primary care – is a significant ongoing problem for every GP. Examples include hospitals bouncing patients back to their GP if they fail to attend a secondary care appointment, expecting GPs to sign patients off from work after surgery and providing inadequate discharge medication. From personal experience, an average of two to three appointments are lost per GP each day to unresourced secondary care work.
The BMA highlighted this inappropriate non-funded workload in its Quality First campaign.1 NHS England has recognised the problem, and has made changes to the NHS standard contract to stop hospitals offloading work onto GPs.2
That said, it’s important to remember that while a minority of consultants act as though GPs are their community house officers, sometimes problems arise because hospitals have poor training or inadequate processes. Consultant colleagues report it can be impossible to find Med3 forms, or they have draconian restrictions on access to hospital prescription forms. We should also be mindful that not every patient-reported request from a consultant is true.
GPs also need to ensure they always comply with the GMC’s Good Medical Practice, which requires doctors to work collaboratively and to treat colleagues fairly and with respect.3
The practice manager or another partner should therefore have an informal discussion with the GP. It will also be important to ask whether the GP is reacting this way because of illness, excessive workload, or burnout.
To help all GPs resist inappropriate workload more effectively, the practice should develop a central process to deal with it. Find out if the LMC or CCG has a process for reporting complaints and write to the trust medical director and chief executive, the local MP and the CCG about ongoing issues.
Dr Grant Ingrams is a GP in Leicestershire
Dr Farah Jameel: Have policies and templates in place
A significant amount of GPs’ time could be freed up if they did not have to rearrange hospital appointments and chase test results. While the partner is right to challenge unresourced workload shift, a rude and aggressive approach needs to be reconsidered. The GMC’s advice on working collaboratively is helpful for this specific scenario.3
It is certainly worth having a practice meeting to discuss the partner’s approach. Everyone deserves to be treated with respect; rude and aggressive behaviour is not justifiable under any circumstances. The practice should seek to explore and understand the reasons behind this behaviour.
The practice as a unit could consider developing a policy to push back on inappropriate hospital requests that breach the standard contract. Ensure all GPs in the practice are aware of the new hospital standards2, and use the BMA Quality First templates4, or an equivalent of your own, on each occasion that a hospital fails to meet them. Embed the templates into your clinical system for automated use; your CCG IT lead could help. Keep a record of all breaches and notify the CCG and LMC so they can raise this issue on your behalf.
Good organisation of care across the interface between general practice and secondary care is crucial in ensuring patients receive high-quality care and the best use is made of NHS resources. This is reinforced in NHS guidance for hospital clinicians and managers.5
Dr Farah Jameel is GPC England executive lead for workload
Medicolegal view: Consider patient safety first
From a medicolegal point of view, we would have concerns if the partner’s actions adversely affected patient safety. If, for example, the partner failed to action secondary care requests this would be a serious breach of his duty to patients and might result in a referral to the GMC.
Likewise, rudeness, aggressive behaviour and a lack of respect in clinical teams can compromise patient safety and add to the risk of complaints.
Addressing conflict can be a daunting process but if you believe patient safety is at risk, it’s important to deal with it early and seek the support of other colleagues.
The GMC has made it clear that doctors have a duty to take steps when they have concerns about a colleague’s fitness to practise.6
It is important to look at the events as objectively as possible. Are the concerns shared by other members of the team?
It would be worthwhile to then discuss the issue directly with your partner. Difficulties can arise if the colleague fails to acknowledge the concerns, and refuses to engage in local intervention. If concerns about the GP are genuinely held, supported by adequate evidence, further steps are then necessary. The GMC guidance states that in such
cases, ‘it may be appropriate to raise it outside the practice – for example, with the medical director or clinical governance lead responsible for your organisation’.5
Ensure you keep records of your concerns and any steps you have taken. The GMC states that doctors will be able to justify raising a concern even if they are mistaken, provided they do so on the basis of reasonable belief and through appropriate channels.
Dr Greg Dollman is a medical adviser at MDDUS
1 BMA, 2015. Quality first: managing workload to deliver safe patient care tinyurl.com/y7ps3wt7
2 NHS Standard Contract 2017-19. tinyurl.com/hospital-contract
3 GMC, 2013. Good Medical Practice. Working collaboratively with colleagues. Paragraphs 35-38. tinyurl.com/y9h5rnxz
4 BMA. Quality first templates. tinyurl.com/ybrwt8db
5 NHS England and partners, 2017. The interface between primary and secondary care: key messages for NHS clinicians and managers. tinyurl.com/y6uwgq9w
6 GMC, 2012. Raising and acting on concerns about patient safety.tinyurl.com/y9z78jkz