Primary care often ends up being treated as a ‘dump’ for secondary care. LMCs, the BMA and groups such as GP Survival and Resilient GPs worked hard to mount a fightback to stem the flow and gave some tools to practices to use, as well as managed to get support from NHS England within the NHS contract 2017-19. It will only be fair to say that many hospitals and commissioners had started to take notice of the issue with some success.
However, during the pandemic, not only was the majority of outpatient activity suspended, but patients who were already being followed up in secondary care were also discharged back to be re-referred if needed. Radiology investigations were rejected, to be re-referred again. This defied logic.
Secondary care has huge administrative capacity compared with an average practice, and the approach of blanket discharges by many specialities made no sense at all. Instead, surely, it would have been less onerous and safer for all to instead suspend the activity, rather than being sent back. Again, what happened on the ground has been very different from the advice from NHS England, which suggested that GPs should continue to refer to secondary care.
More worryingly, increasingly, a lot more tasks are being transferred to primary care, and seem to imply that somehow, it’s safer for patients to be seen in primary care than in hospitals. Being asked to check blood tests, follow up with patients, and then let the patient and secondary care know, as ‘we’re in a pandemic’ appears to be the new norm.
This is a particular concern as hospitals move into the recovery phase
One service will not refer to the other, or even within another part of the same service. Not only does this add to unnecessary work for practices and takes away precious clinical time, but it causes frustrating delays for the patients too. We’ve been asked to check patient saturations, send sputum samples, carry out spirometry, and then let secondary care know that this has been done. Neurology has asked us to refer patients to stroke services. Midwives and health visitors are requesting scripts because they don’t have anyone else; hospitals asking us to prescribe because they can’t do prescriptions remotely – the list is endless and increasingly large.
Primary care has always been well ahead of any other part of the NHS when it comes to the use of technology and innovation and we take pride in it, be it the use of digital records, electronic prescribing, or even telephone consultations, which practices adopted more than a decade ago. Yet this doesn’t excuse hospitals switching to telephone, virtual and other remote ways of working, leaving primary care to end up picking up the pieces.
This is a real concern as hospitals move into the recovery phase. As we work for the next year or so in a new uncertain environment, our capacity is limited and we’re likely to struggle in dealing with the massive backlog of thousands of referrals, impending mental health pandemic and health needs that have been postponed. We cannot and must not become the ‘dump’ yet again, especially when there is little chance of transfer of any resource in an NHS battered by the austerity and the pandemic.
There are already some indications that we may be instructed to carry out more tests on behalf of secondary care. A simple blood test now takes twice as long and requires PPE to be worn. Our commissioning colleagues, as well as national leadership, the LMCs, and the BMA, must take lead and act on this quickly. Any work transfer must be mutually agreed nationally; must be followed by fair resource; and must have safeguards in place to ensure only agreed work is transferred.
In the ‘new normal’, it’s vital for primary and secondary care to work in sync and with each other. The goodwill of primary care in supporting hospitals and other parts of the NHS with workforce, as well as managing the demand, must be recognised and respected.
Dr Kamal Sidhu is a partner at Blackhall and Peterlee Practice and New Seaham Medical Group; chair at South Durham Health Community Interest Company; and vice-chair at County Durham and Darlington LMC. He writes in a personal capacity.