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End the dysfunctional primary-secondary care interface to improve GP access

End the dysfunctional primary-secondary care interface to improve GP access

GPs should be dedicating their time to treating patients’ health needs – not their hospital appointment queries, says Dr Chaand Nagpaul CBE

As Steve Barclay commits to slashing ‘time-sapping admin’ in the NHS, my message to him is to tackle the dysfunctional primary-secondary care interface as an immediate priority. It is leading to division, duplication, delays to care and wasteful workload, which is directly impacting the daily lives of patients and doctors in both general practice and hospitals.

While BMA council chair, I led the Caring Supportive Collaborative project, which showed that 74% of GPs and 52% of hospital doctors felt the primary-secondary care divide was harming the quality and safety of patient care. Seven in 10 doctors said it was driving up bureaucracy and administrative costs.

An NHS England report in 2015 estimated that 15 million GP appointments annually are spent dealing with hospital administrative queries – appointments that could and should be available for patient care instead. This figure is likely to be higher today, given the record backlog of over 7 million people on waiting lists in England, which is fuelling increasing numbers of patients attending their GP practice daily to chase their clinic or operation dates and requests to expedite their treatment.

Demoralising and de-professionalising

Not only is the workload inappropriate, but it’s also demoralising and de-professionalising for GPs to be reduced to hospital-appointment-query clerks when they should be using their precious time, knowledge and skills treating patients’ health needs. Further, GPs and their staff not uncommonly suffer abuse from patients frustrated by obstacles when contacting hospitals only to be told to see their GP instead – who themselves have no direct ability to sort out their problems. This usually incurs the bureaucracy of writing to the hospital merely repeating what the patient has told them. Nor is it the right answer for secondary care, creating additional administration and inefficiency within trusts.

With health ministers across the political spectrum pronouncing improving GP access as a priority, the focus should be on putting an end to the scandalous waste of up to tens of thousands of GP appointments and countless hours of staff time daily on hospital related bureaucracy. This requires dedicated, accessible local helplines and online support for patients regarding their hospital care, with the clear message to not contact their GP.

Another example of primary-secondary care dysfunction is the standard request for GPs to prescribe hospital-initiated outpatient medication. It defies logic and operational efficiency to have a system where a hospital doctor initiates medication but then tells the patient that they are unable to prescribe it. This is followed by a letter to the GP to issue it, often inconveniencing the patient to contact the practice, then for the patient to pick up the prescription two days later – with the possibility of further delay if the GP has not got adequate information or is clinically uncomfortable to prescribe. These multiple steps could be circumvented by a keystroke by giving hospital clinicians the ability to prescribe using the electronic prescription service (EPS), with the patient able to collect the prescription immediately from a community pharmacy of their choice.

EPS for hospitals would also allow specialists to take appropriate clinical responsibility in remote consultations by prescribing directly to the patient’s local pharmacy as well as on an ongoing basis for specialist repeat prescriptions between clinic appointments. It would not matter that the patient may be geographically remote. It would be safer for patients, by ending GPs feeling coerced to prescribe specialist drugs outside their competence, or to prescribe for patients they themselves had not clinically assessed. Clearly, there would need to be budgetary adjustments to account for hospitals increasing their prescribing of drugs that are currently being issued in general practice.

In a similar vein, another avoidable bureaucratic demand on GP practices are secondary care requests to arrange investigations in the community, with the rationale that it would be unreasonable to expect patients to travel back to hospital for investigations such as blood tests. The increase in hospital telephone clinics is further fuelling such requests. The obvious solution is to enable hospital doctors to remotely electronically book patients directly for investigations in local community settings, bypassing the GP practice altogether. This would require investment in both IT and community diagnostic capacity – this is already a stated aim by NHS England in its proposal for community diagnostic hubs – but this needs to become a living reality nationally.

These changes will equally benefit our hospital colleagues. It surely takes longer to write a letter to the GP detailing a request for a prescription or investigation than what could instead be a simple keystroke to action it directly. Indeed, the BMA has previously sent joint letters between the chairs of the BMA’s consultants and GPs committee to NHS England specifically calling for hospital clinicians to have access to EPS and diagnostics in the community.

It’s also important to ensure that the standard hospital contract provisions in England, which were negotiated while I was GPC chair, are adhered to – stipulating that hospitals are responsible for informing patients of secondary care investigation results, not discharging patients for a GP re-referral after failing to attend outpatient appointments and making direct internal referrals for related conditions.

With a crisis of acute GP shortages and demand outstripping capacity, the Government has a moral duty to decisively end the ludicrous bureaucratic workload emanating from the primary-secondary care interface, which is diverting GPs away from caring for patients.

Like most GPs, I long for the day when I can go into work and do my job as a GP without a single distracting interaction trying to deal with hospital-related appointment queries and bureaucracy. Taken together these measures could quite literally free up millions of GP appointments annually, improve morale and increase access to care for patients in both general practice and hospitals.

Dr Nagpaul CBE is a GP partner in London and vice chair of Harrow LMC. He was past chair of BMA Council (2017-2022) and BMA GPs committee (2013-2017). He writes in a personal capacity.



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

Ian Pidgeon 23 November, 2022 10:39 am

I would love to post several of the paragraphs here on our practice webpage… jsut to let the patient population know I’m NOT being unreasonable by suggesting THEY pick up the phone and call their urology/ortho secretary themselves!

Paul Hartley 23 November, 2022 10:40 am

These are very sensible proposals, let’s hope this time they are put into practice.

Patrufini Duffy 23 November, 2022 4:50 pm

Once a referral is triggered, there is no further discussion with primary care. Not funded the same, not treated the same. Talk to PALS, go walk down to their secretary or go Private. End of conversation. Oh – “patient could not be contacted…they’ve been discharged”. And that’s all legitimate, and you can’t deduct a patient without a rigmarole of reasons why.

Carpe Vinum 24 November, 2022 9:57 am

What a ridiculous article! In this modern era of NHS insanity, to be proposing a series of well thought out, actionable and reasonable proposals which would actually have a beneficial effect on NHS functioning and improve the lives of clinicians and patients is tantamount to heresy and worthy of the ducking stool….

David jenkins 26 November, 2022 8:03 pm

“EPS for hospitals would also allow specialists to take appropriate clinical responsibility”

yeah – fat chance !!

if you could dump all the risk for all your remote consultations, would you vote to change it ?

didn’t think so !

Prof Mitch Blair 29 November, 2022 12:33 pm

Chand – you ar SO correct in your prescription to the NHS- all suggestiosn are doable here. As you are aware , we are testing out consultant paediatric clinics in practices in Harrow, Brent and Ealing with great success in terms of improving communications and trusting relationships between specialists and primary care staff. These are enhanced with monthly multidisciplinary MDTs which have been extremey well attended by GPs , AHPs , social care and community nursing services as well as CAMHS. Cuts out the rubbish and gets things moving for so many patients. What is needed is some incentivisation for expansion and an economic modelling which makes this routine business for all. ( on its way with NW London ICB) Palliative care and ENT very much on board in my neck of the woods too. Just ask around and you will see that this is professionally very satisfying and removes huge chunks of unecessary time wasting admin. Replace transactional with relational medical practice !

Simon Gilbert 2 December, 2022 10:31 am

Our local trust won’t put in place specialty email boxes for GPs to liase with doctors/nurses/other therapists about mutual patients (often illogical prescribing advice or to let them know about new or relevant patient information) as they can’t trust themselves to check them.
They advised use advice and guidance for all such queries.
Advice and guidance response from the consultants who didn’t get that memo is that that isn’t the correct route for queries about ongoing patients!