Rachel Carter takes a look at NHS England’s new pledges for reducing unnecessary GP bureaucracy
The Government’s latest recovery plan for general practice has sought to address an issue that has plagued GPs for years: secondary care ‘workload dump’.
This takes various forms but can include patients being sent back to their GP for further tests or investigations, or for onward referral to another consultant, or patients asking their practice to follow-up appointments on their behalf.
The recovery plan set out four measures aimed at reducing the time practice teams spend on ‘lower-value administrative work’ and work generated by issues at the primary-secondary care interface, which it said practices estimate they spend 10% to 20% of their time on.
On the face of it, these are some of the key areas GPs urgently need addressing: responsibility for onward referral; fit notes and discharge letters; call and recall, and clear points of contact for communicating with consultants.
But this is not new, even when it comes to NHS England plans. It was mentioned in the GP Forward View before. And if recent reports are anything to go by, there has been limited success.
Onward referral
What the plan says
If a patient has been referred into secondary care and they need another referral, for an immediate or a related need, the secondary care provider should make this for them, rather than sending them back to general practice which causes a further delay before being referred again.
What difference will it make?
The 2016 GP Forward View made a similar pledge, stating that onward referral in the same hospital for a non-urgent condition related to the original referral was ‘permitted’ and there was no requirement to refer back to the GP. It is also already in the NHS standard contract. But despite this, anecdotal reports from GPs suggest that onward referral is still an issue.
In July last year, Cheshire and Merseyside ICS produced a consensus document designed to tackle inappropriate transfer of work between hospitals and GPs – and one of its main principles was that onward referrals between specialists should be arranged directly. And this month, Camden LMC issued a message to practices encouraging them to submit ‘quality alerts’ to ICBs when they experience workload dump from hospital trusts, which also reiterated that ‘referrals from one consultant to another should be done directly’ where related to the original.
The plan does not indicate that NHS England will be taking any further steps to enforce this, other than ICBs being asked to provide a progress update later this year.
Complete care (fit notes and discharge letters)
What the plan says
Trusts should ensure that on discharge or after an outpatient appointment, patients receive everything they need, rather than – as too often happens now – leaving patients to return prematurely to their practice, which often does not know what they need. Therefore, where patients need them, fit notes should be issued which include any appropriate information on adjustments that could support and enable returns to employment following this period, avoiding unnecessary return appointments to general practice. Discharge letters should highlight clear actions for general practice (including prescribing medications required).
Also, by 30 November 2023, providers of NHS-funded secondary care services should have implemented the capability to issue a fit note electronically. From December this means hospital staff will more easily be able to issue patients with a fit note by text or email alongside other discharge papers, further preventing unnecessary return appointments.
What difference will it make?
GPs will have heard much of this before. The Forward View made a similar pledge on discharge summaries, urging hospitals to provide these in the standardised format agreed by the Academy of Medical Royal Colleges, so GPs could find ‘key information in the summary more easily’.
And the fit notes requirements are not new. A planned overhaul for how fit notes should be provided was announced in 2021, indicating that these should be fully digital and that hospital doctors should be encouraged to issue them to reduce GP workload. The plans, including to embed electronic fit notes in hospital systems from spring 2022, were also highlighted in former health secretary Sajid Javid’s GP access plan in October 2021.
Call and recall
What the plan says
For patients under their care, NHS trusts should establish their own call/recall systems for patients for follow-up tests or appointments. This means that patients will have a clear route to contact secondary care and will no longer have to ask their practice to follow up on their behalf, which can often be frustrating when practices also do not know how to get the information.
What difference will it make?
This is likely to be welcomed by GPs, who have anecdotally reported that chasing hospital follow-up on behalf of their patients now represents a significant chunk of their workload as a result of the pandemic backlog. It is not clear when NHS trusts will be expected to establish their own systems.
Clear points of contact
What the plan says
ICBs should ensure providers establish single routes for general practice and secondary care teams to communicate rapidly: e.g. single outpatient department email for GP practices or primary care liaison officers in secondary care. Currently practices cannot always get prompt answers to issues with requests, such as advice and guidance or referrals, which results in patients receiving delayed care.
What difference will it make?
This was also highlighted in the GP Forward View, which said a working group would be established to look at the interface between primary and secondary care, including practical steps to enable better communication between GPs and consultants and how to improve GP access to consultant advice on potential referrals. ‘Advice and guidance’ has since become a major part of NHS England’s plans to tackle the Covid backlog – with a mixed reception from GPs. A direct route for communicating with secondary colleagues is likely to be welcomed though.
What’s missing?
While the profession may have heard a lot of these promises before, it is potentially positive to at least have them reiterated. But GPs commenting on the plan noted two glaring omissions on workload dump – its failure to address the ‘pre-referral’ work they are expected to do, and secondary care passing back responsibility for further investigations, such as blood tests or prescriptions. Sajid Javid’s 2021 plan said secondary care providers should be held to account over the latter. But it appears this is still a major problem for some GPs, with one LMC last year creating a template letter that returns such requests to the hospital itself citing extreme workforce pressures.
It also remains unclear whether NHS England will take action to enforce these measures. The plan states that ICBs must address these four areas and will be expected to provide an update to their public board in October or November 2023. In the meantime, GPs may not be holding their breath.
