GP leaders are pushing back against hospital trusts rejecting referrals, with LMCs issuing warnings of potential contract breaches.
A number of LMCs have encouraged GPs to send warnings back to providers who reject their referrals, stating that there are no valid grounds for the rejection.
Some template letters produced by LMCs to help GPs do this are badged as part of collective action efforts, since the BMA’s ‘menu’ of actions encourages GPs to ‘stop rationing referrals’.
It comes after Pulse revealed that GPs are concerned about a rise in rejected referrals and particularly from ‘anonymous’ clinicians, with referrals coming back to general practice unsigned, and patients being put at risk when secondary care and other providers do not accept GP referrals.
Now several LMCs have said that secondary care providers are required to accept referrals under the NHS Standard Contract, and this was backed up by the BMA’s GP committee chair, who told Pulse that trusts are ‘contractually obliged’ to accept GP referrals.
North and South Essex LMCs said it had ‘secured legal advice’ which confirmed this, in a recently shared template letter.
GPs in this area have been encouraged to write back to providers saying: ‘Having sought advice from our LMC who have in turn secured legal advice, we write to remind you that the [Trust] is contractually required to accept referrals pursuant to the NHS standard contract and, in particular, the Service Conditions (‘SC’) that attach to the same.’
These service conditions state that providers can only reject referrals if the patient is not located within the relevant ICB area or if the referral was not made via e-RS.
For instances where GPs feel their ‘clinically appropriate’ referrals was rejected on grounds other than this, the template letter argues that ‘rejection is not an option available’ to trusts and it ‘represents a breach of [their] contractual obligations’.
In Nottingham, the LMC has put together a similar letter – signed by its chair and medical director – which GPs can use to push back against referral rejections.
It said: ‘Having reviewed the referral letter and reflected on both the contractual and the GMC obligations, the referring GP is satisfied that the referral was clinically appropriate, details the required information to ensure a safe transfer of care to yourselves, and is in line with both the NHS Standard Contract 2024/25 Service Conditions: Acceptance and Rejection of Referrals 6.13 Subject to SC6.3 and to SC7 (Withholding and/or Discontinuation of Service), and the Primary Medical Services Contract.
‘It therefore meets the required contractual and professional obligations for referral.’
The letter also referenced GMC guidance which requires GPs to ‘refer when clinically necessary to do so’.
It continued: ‘We are committed to putting the needs of our patients first, using limited NHS resources efficiently, and working in positive collaboration across our local integrated care system.
‘We do not believe that your trust has any grounds for rejecting this referral and would be grateful if you could arrange for this patient to be offered an outpatient appointment or other clinical assessment.
‘Failure to do so may cause delay to patient care and could cause potential harm.’
Londonwide LMCs has published a letter template for use during collective action, which tells secondary care providers that if they ‘disagree’ they should ‘take this up with [the] local commissioner’.
The BMA has previously published guidance on referral forms which states that GPs are not contractually obliged to use certain proformas in order for their referral to be accepted.
A template letter put together by the union says that ‘professional regulations make no mention of the use of referral forms or proforma’ and requests that the trust accepts the referral ‘in its current form’.
GP Committee England chair Dr Katie Bramall-Stainer told Pulse that hospital trusts are ‘contractually obliged’ to accept GP referrals, except in ‘very limited circumstances’.
She said: ‘Should a trust reject a referral for other reasons, for example arbitrarily reducing activity, they risk breaching their contracts; trust management must ensure hospital colleagues are aware of this.’
She said that part of the BMA’s collective action is ‘pushing back against bureaucracy’ and instead referring ‘where and when it is clinically appropriate’, which is ‘perfectly legal and safer for patients’.
‘We understand that hospital staff working in referral management may be under pressure to minimise activity and reject these referrals, but this is the reason why we’re taking action in the first place,’ she added.
‘These measures don’t help patients, often cause unnecessary delay to their care, and add hours of paperwork for GPs.’
Pulse approached NHS England for comment.
Well done to all those LMCs publicly pushing back on this.
For years, GPs have been effectively bullied by Trusts into accepting unfunded transfer of workload, in the shape of forms and proformas and ‘guidelines’ that effectively require the GP to perform a whole set of actions that would previously have been undertaken (and funded) in outpatients. The underlying threat has been ‘do exactly as we ask, or we reject the referral and your patient suffers.’
Despite what the trusts and outpatient departments say – and perhaps even believe – they do not have the right to impose these forms on general practice.
Use of forms (especially those imposed without consultation) has never had a contractual basis, and GPs have always had the right to refuse to use them.
On the other side, trusts do not have the contractual right to refuse referrals, as long as they are done via eRS. It doesn’t matter if the GP has refused to use the form, and it doesn’t matter if the GP hasn’t attached serial serum rhubarb results or scanned their toes: the hospital has to accept the referral *as long as the referral is appropriate and contains enough information to enable a safe handover of care*.
Of course, if a form is self-populates and saves the GP time, it will be quickly and widely adopted by GPs: but too often they are done to shift workload, or even implemented inflexibly so as to act as a barrier to care – and the interests of the GP and the patient are not considered.