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Micro-annoyances cause macro-exhaustion

Micro-annoyances cause macro-exhaustion

Columnist Dr Copperfield is left speechless and exhausted after yet another referral is bounced back

You might wonder why I’m going to bang on about that old chestnut, ‘Little things that grind GPs into a state of gibbering despair’. Well, it’s because I’ve just reached what is indisputably peak micro-annoyance.

I don’t care how irritating, petty or ridiculous the requests and demands are that you receive, because I guarantee I can now out irritate, petty or ridiculous you.

Admittedly, the day had rather primed me for the moment. Indeed, the following (verbatim) ‘GP to do list’ on a discharge letter was just one example of many and suggested that I was on some kind of roll:

‘GP to kindly follow up with U&Es at four weeks.’

‘Please kindly perform a CXR in six weeks for resolution of pathology.’

‘Please kindly follow up on further investigations and outpatient review.’

‘Please kindly perform routine bloods for resolution of inflammatory markers.’

Sigh, and so familiar. It’s not so much the work as the ingratiating ‘please kindly’ that really grates. It’s like an executioner saying to you, ‘Do you mind awfully that I cut your head off?’

But this was a mere foothill compared with the summit I was about to scale, which went as follows. Rarely, for me, and somewhat in desperation, I had referred someone to an NHS chronic fatigue service. This required the usual hoop-jumping and referral proforma mandating a polyinvestogram of bloods, duly completed and appended to the referral.

No prizes for guessing what happened next, but definitely one if you can work out why. Yes, it was bounced back. Because… deep breath, relax… ’we are rejecting this referral because the investigation results have to be written in the boxes provided on the referral form, not appended as an attachment’.

You might reasonably suggest that I’ve made this up, but only someone with a truly grotesque imagination could have done so. So, yes, I might have done. But I didn’t.

My problem is, this is so beyond absurdity that I literally can’t articulate a suitable response. I don’t have the words to convey the, well I can’t. Nor the energy. Because, suddenly, I feel profoundly and pathologically tired. Exhausted with life, in fact.

Kindly check my bloods, would you? And send me the results in boxes.

Dr Copperfield is a GP in Essex. Read more of his blogs here



Please note, only GPs are permitted to add comments to articles

Victoria Cleak 27 July, 2023 12:01 pm

I had to fill out the same information on three separate forms to get a patient urgently seen by the right team.
Admin is king. The patient is secondary. This is what happens when healthcare is run by people who can only work in straight lines and not literally think outside the box. As patients don’t fit in boxes, the system is not fit for purpose.
Doctors are trained to think for themselves. Other professions not so….

Peter McEvedy 27 July, 2023 12:09 pm

The plethora of forms, none of which are similar and then get bounced to another lesser service drives me crazy – Child psychiatry would seem to be particularly awful. Most usually require input from the school but unsurprisingly the schools try to avoid filling them in as they take considerable time to avoid just straight rejection.
Adult psychiatry no better – we have actually employed two CPNs ourselves as otherwise our patients wait for months – what is even worse, the psychiatry letters to patients suggest the patient use this service rather than actually seeing them. I think any block contracts should be withdrawn so they only get paid when actually seeing patients and primary care charges them for work done requested by them outside what would normally be required.

Michael Mullineux 27 July, 2023 12:25 pm

Yeah drives me absolutely puce. Wrong form, wrong box , no recent CRP and my absolute favourite, rejection of Gynae 2/52 referrals if weight is not included in referral (for potential ovarian pathology – really??). Oh and don’t even get me started on obsolete forms lurking in DXS to catch me out with the standard – ‘please complete latest iteraton of our form’ response. But I quite enjoy fighting back and pointing out the pedantry attached to these responses and have designed a standard form rejection response form to this end.

Stephen Fowler 27 July, 2023 12:43 pm

It might be worth noting that we are not contractually required to fill out any of their forms – they are contractually required to accept a referral in whatever format we send it, as long as all the relevant information is included – after many simiiar experiences I have had this confirmed by the CCG or ICB as they are now.

So now any such nonsense simply gets forwarded to the primary care team at the ICB, with a standard ‘please sort out this rubbish’ letter.

Some Bloke 27 July, 2023 1:09 pm

me to, I am fighting this mud-field and sending referrals back with reminder that these b..rds are contractually obliged to accept referral with minimal data set and whatever necessary information is included (not where, in which box, it is). copy to ICB, short message to patient to advise that their referral is being delayed due to lack of co-operation at hospital end.
but makes your blood boil- untill I remind myself that referral management teams are, in fact, staffed by mostly half-litterates who hardly secondary school level education, if lucky.

John Graham Munro 27 July, 2023 2:15 pm

Why do 90yr old patients referred to the ”memory clinic” need a chest X-Ray.?

Decorum Est 27 July, 2023 3:02 pm

I recollect a patient with classical appendicitis, arriving in A&E, back in the early 80s, with the referral written on the torn-off back of a cigarette packet ‘? Abdominal pain’. Seemed a bit minimalist but in fact was all that was needed.

Dylan Summers 27 July, 2023 3:17 pm


Or – locally – cholesterol?

Dylan Summers 27 July, 2023 3:17 pm

I mean @JGM

Don’t know why it came out as @JMC!!

Michael Mullineux 27 July, 2023 3:28 pm

@JMC and @DS: locally U-mcs for all referrals despite a clear history of gradual cognitive decline over many months without any indication of urinary Sx

Some Bloke 27 July, 2023 3:48 pm

all, without cholesterol, mcs or CXR it is not possible to tick relevant boxes, that’s why they are needed. that’s probably all tat “memory nurse” understands about the value of these investigations too. oh, no! they also know, if result is in RED- send it to GP to “take appropriate action” as per protocol.

David jenkins 27 July, 2023 4:36 pm

sent a request off for abdo uss – “episodic abdo pain consistent with gallstones”

i thought that was concise, and said it all.
bounced back “not enough clinical details – what is the clinical question ?”

i returned, with the following, sent to the local chief radiologist, and the hospital director with the comment “do you think returning this form was a good use of time”

“female, fair, fat, fecund, forty, episodic pain in ruq, fat intolerance. clinical question – HAS THIS PATIENT GOT GALL STONES ?”

scan done………………………..gallstones. i encouraged the patient to write in to the radiologist too. they absolutely hate getting letters from patients. goodness me…….patients writing in ?……………..that would never do !!

didn’t get an answer to my complaint though !

p.s. hywel dda university health board

Anonymous 27 July, 2023 7:25 pm

Most of these requests for follow up come from inexperienced SHOs who blindly follow their consultants requests not even questioning the stupidity of such requests.

Repeat CRP in a week? Repeat UEs in a week? Chase the outstanding vitamin D level…

You have to have a standard ‘no thank you’ response to the consultant in charge with the junior cc’d (purely for their learning).
Increases workload for your admin, but saves you whining on here later.

Some Bloke 27 July, 2023 10:38 pm

Anonymous, read posts above

Nigel Rowell 28 July, 2023 9:46 am

I recall being asked to “chase” something or other.
I replied “Thanks for asking me to chase this result. I have passed your request to my labrador, who is the only member of my team who chases things”

Janine O'Kane 28 July, 2023 7:31 pm

We constantly get discharge letters with repeat this that and the other from 3 days to whatever
Do you not do this in England then?
Our TR is full up with our own stuff
Advice please

Mark Funnell 28 July, 2023 7:53 pm

I have certainly written back once to a consultant & pointed out to him that I am not his junior doctor

I have also bounced back requests to refer to community physio & SALT pointing out that if they have made a decision then they must have a question to ask or a reason to ask for input & as I have no idea what these are then perhaps they would like to write their own requests

Some Bloke 29 July, 2023 9:00 am

Janine, a lot of it happens in England. We look at requests and make clinical decision taking into consideration resources and workforce available. Often bounce unrealistic requests back to hospital or change time of testing to what is realistically possible.
A lot of their idealistic overoptimistic planning is based on poor understanding of realities on the ground, as well as covering their arses.
Gynaecologist: kindly arrange for patient to have some psycho-sexual counselling. Me: kindly arrange it yourself.
Psychiatrist: you could try this antipsychotic, but then you must do an ECG on this housebound patient week or two into their treatment. Me: arrange admission and start your own treatment and monitoring.
Orthopod: please support patient with weight loss. Me: here’s healthy living/eating leaflet and website for weightwatchers that you can pass on to patients without any need for my permission in the future.
all bloods etc- I will reallocate time to realistic and necessary.
makes sense?

Deborah White 31 July, 2023 11:48 pm

I had a referral rejected recently because my ticks were NEXT to boxes rather than IN them. Any consultant doing this, or having this done in their name, should be embarrassed.

Simon Gilbert 1 August, 2023 11:43 am

“I had a referral rejected recently because my ticks were NEXT to boxes rather than IN them. Any consultant doing this, or having this done in their name, should be embarrassed.”

Consultants have successfully managed to avoid responsibility here. Their specialist nurses often don’t have the responsible consultant name or even secretary email on so there is no one to bounce back to. The referral rejections are from ‘the team’ without even the name of the administrator on. The route to bounce back a rejected referral is purposefully opaque so there is an obvious trackable GMC/coronal/legal asymmetry between the ‘identified aware GP’ and the ‘aware secondary/community/mental health organisation’ – even when challenged they can’t find the emails!

Centreground Centreground 1 August, 2023 5:41 pm

I am glad specialist nurses have been raised as we are being inundated by these group who clearly have some value but make everyone feel to some extent inferior as they expect others who deal; with wider ranges of illness to have knowledge to each of their levels, as they spend an entire job looking at one single disease area. Unlike Consultants, they are without ultimate responsibility as they will be able to pass back difficult cases to the GP to refer or an unnamed Consultant whom they are more easily able to contact.
They should be more appropriately named e.g. Diabetes Limited Nurses or COPD Limited Nurses as they are limited to one single disease area and this specialist title should be more apt for GPs or specialist practice nurses who need to have far more extensive and wider knowledge!

Anonymous 2 August, 2023 5:31 pm

Referral bounced back from cardiology specialist nurse because patient with exertional chest pain has a history of mild aortic stenosis. Advised to refer to consultant clinic.
Surely, this could have been streamlined directly from the nurse who feels they won’t be able to manage this, directly to their consultant?!
A passive aggressive message to ensure the patient does not attend their clinic.

James Weems 2 August, 2023 8:41 pm

This whole post and comments has raised my blood pressure too high!
Also, beware the OPT IN LETTER!
DSNs in our area demand we refer an emailed form to them (iterations of which change almost fortnightly to catch you out) but then send out a PAPER form to the patient which they must SEND BACK in order to opt in! Despite being referred by a competent nurse or GP. Why why why why?
Flagged as pointless and dangerous to ICB/LMC and back to nameless person at DSN.

Dr No 3 August, 2023 8:40 pm

Our local talking therapies provider will not accept correspondence from GPs, insisting on patient self-referral. Even when I’ve written a beautiful and extensively explanatory letter about said patient. The proliferation of forms is killing GP letters. I spent 35 years perfecting concise, information efficient prose. All this is lost in the pro-forma. Another nail in the coffin… I’m off very soon, so the next nail won’t be in MY coffin,

Andrew Walton 4 August, 2023 8:57 am

Perhaps we need a rejection form – if not completed the rejection can be rejected!

Jaiker Kumble 5 August, 2023 10:58 am

It is not micro annoyance -a major irritation!Often,I get asked to refer to another specialist within the trust and I point out this can be done by the specialist himeslf without getting me involved-it works!
Couple of times when asked to do some blood tests,I asked who should I charge for my services-but never got a reply-was not asked again.

Dylan Summers 5 August, 2023 11:15 am

@Andrew Walton

Sir, you have won.

David Banner 8 August, 2023 9:28 pm

Hopefully everyone realises why this bouncing is being done. It’s purely to manipulate waiting lists. Keep rejecting referrals and….. Hey Presto!….boxes ticked and targets achieved.
Make it as difficult and infuriating as possible for GPs to refer, they’ll soon lose the will to keep fighting and give up trying.
Invented and perfected by CAMHS, enviously copied by everybody else.
The Patients?? Ach, who cares about them.

Truth Finder 9 August, 2023 2:32 pm

All signs of a system that promises a lot but cannot deliver. The service is there but in name only. There is no proper service available.