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.