GPs have raised concerns about a rise in rejected referrals to secondary care, and particularly those from ‘anonymous’ clinicians.
Many GPs told Pulse they have noticed more letters coming back which are unsigned and do not state the name and title of the staff member actioning the rejection.
The BMA warned patients are put at risk and their ‘condition could worsen’ when secondary care and other providers do not accept GP referrals.
Norfolk GP partner Dr Ankit Kant estimated that 20 out of a total monthly 215 referrals come back as rejected at his practice, of which the majority are anonymous.
This means his team do not ‘know the level of experience of the person’ who decided to reject the referral, which he said causes ‘significant’ medico-legal risks.
Dr Kant told Pulse: ‘Often it takes a number of weeks to hear back from the team that a referral is rejected – with patients assuming that they will be seen.
‘We then have to use up our valuable appointments dealing with understandably unhappy patients. It should be a very rare event that a referral is rejected. We can manage most things as generalists and know when we need expertise from colleagues.’
Nottingham LMC chair Dr Shan Hussain said that the number of rejected referrals GPs deal with has ‘got worse over the years, without a doubt’ and that anonymous letters from providers are ‘common’.
He said the anonymity suggests that ‘non-medical individuals’ are dealing with and rejecting GP referrals.
‘I think if it was a doctor, they would sign it as a doctor. You’ve got to put a name to a referral letter. We’re sending a referral letter with our name and details, we should expect the same in return.’
Dr Hussain also said that if something went wrong in the patient’s care, he ‘suspects clinical responsibility would lie with the GP’.
‘This is a nameless rejection letter, so we don’t really know who to contact to identify the individual that’s made this rejection, or indeed what their qualifications are,’ he added.
Responding to Dr Kant’s concerns about anonymous rejected referrals on X, Hertfordshire GP Dr Neena Jha said they are ‘completely unacceptable and dangerous’.
‘As a GP every time I refer a patient to hospital I write my name, title, place of work and contact details,’ she said.
GP Committee England chair Dr Katie Bramall-Stainer stressed that GPs ‘only refer when clinically necessary’, meaning patients can deteriorate if they ‘do not get the specialist attention they require’.
She told Pulse: ‘When referrals are rejected – sometimes with little explanation or opportunity to respond or challenge the decision – it delays patients getting the care they need and adds more bureaucracy to already overworked and exasperated GPs and practices.’
While Dr Bramall-Stainer recognised the ‘unique pressures’ hospitals are under, she said that ‘when GPs are unable to refer, the need for care does not suddenly disappear’.
She added: ‘Practices are themselves working at capacity, and as they take on more work, looking after patients who are waiting for or unable to access care elsewhere in the system, the backlog in general practice only gets worse and it is patients who suffer.’
Professor Azeem Majeed, a GP and head of the primary care department at Imperial College London, said that ‘having referrals rejected or delayed has become a common experience’ for GPs and patients in England.
He said that this can lead to ‘delayed diagnosis’, increased workload for GPs, as well as increased clinical risk.
Professor Majeed told Pulse: ‘I have noted that specialist services will rarely write to patients to let them know their referral has been rejected, leaving it to the primary care team to inform them, which does not sit well with the concept of a patient-centred NHS.’
He added: ‘For mental health services, in particular, declined referrals can lead to significant delays in accessing therapy or psychiatric support, exacerbating mental health conditions like ADHD.’
NHS England did not respond to Pulse’s request for comment.
One of the BMA’s recommended options for GP collective action is to ‘stop rationing referrals’, and the union highlighted secondary care and other providers cannot oblige practices to use a local proforma for referrals.
Many LMCs have warned about the pressures of ‘workload dump’ on GPs from other providers, with local leaders in Humberside estimating that it costs their area over £4m in NHS funds.
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Simply unacceptable – if I recive similar, I respond immediately rejecting the referral rejection which usually results in an appointment as requested even if routine waits are around 12 months in our locality
Disgraceful approach by hospital consultants (who are no doubt pressurised themselves by NHSE and government) and wishing to remain anonymous, does sound like a choice they make themselves. This is an important and good item published by Pulse. Dr Bramall-Stainer’s comments about deterioration and frustration seem like self-evident truths; but what action will she take? Not a ‘patient-centred NHS’ and ‘delayed diagnosis’ is an obvious concern of all GPs and patients, not only Professor Majeed, ‘NHS not responding to Pulse’s response for comment’ : matters that should probably be pursued by a repeated request to NHS, by Pulse, although they may get an anonymous response and unsigned, just like the response to GPs (which speaks volumes); and publication and discussion,disgust in the other news media and by broadcasters too, might help GPs and patients. These anonymous hospital decisions often UNdo the great work of preventive medicine and worsen the financial cost to this nation. These preventive actions would help patients and is in the interests of patients. Actions speak louder than words in this essential quest, don’t they. What action will be taken against against these anonymous decisions made against GPs and their patients, by some anonymous wet-behind -the-ears trainee nurse, (for all you know), and who should not be put in such a position by their seniors? Broadcast this problem (and so help the NHS).
Well, in fact, either you know which hospital you referred to, or the letter comes from a hospital Trust, of which you can look up the Medical Director on their website, and it is that Doctor (the Medical Director) (unless another specialist is named on the letter) who has authorised and is sending and responsible for the rejection – and bear ini mind that they are NOT a specialist trained in the specialty to which you referred the patient, so the rejection is outside their sphere of experience and expertise, as referred to by the GMC guidance………
The patient could always write to the MD requesting justification for the refusal – – or get their lawyer or CAB to do so on their behalf? Evsn the occasional MP gets involved in such things……
This is a growing trend. The hospitals are rejecting lots of referrals. Presumably some sort of Darwinian strategy to reduce the population?
LMC motion idea ‘GPs can reject any referral rejections that don’t have the name and GMC number of a responsible supervising doctor for that decision.’
Surely the NHS charter which confirms the right of a patient to request and receive a specialist opinion trumps any referral management service. GPs also deserve the right to have a consultant review if they feel they are not able to manage the patient themselves, as they are are otherwise left unsupported.
If the referral is sent there needs to be a very good reason for rejection of the referral without a full clinical assessment and review, only then confirmation that the patient may not need ongoing care of a consultant – perhaps confirming the patient may not meet referral criteria for surgery, but the reassurance a consultant review can provide can help clarify when this decision is very marginal.
The rise in anonymous rejected referrals presents serious concerns about patient safety, transparency, and clinical accountability. GPs face increased medico-legal risks when they cannot identify who is rejecting referrals, delaying necessary specialist care and leaving patients in limbo. While hospitals are under pressure, rejecting referrals without clear communication exacerbates GP workloads, undermines patient care, and heightens the risk of deteriorating health, particularly in mental health cases where timely intervention is critical.
It is disgraceful and the person who rejects the referral from a fully qualified GP should put their name to the letter. I won’t be surprised if it turns out to be a PA or a nurse or worse, a non clinician. Can you imagine the house officer rejecting the consultant’s management plan.
Just returned from leave and had 7 rejections in a week
(2 from radiology rejecting xrays, because the locum wasnt registered at our practice – but they still sent the rejection to us!)
It is a growing trend, and I think a lot come from secretaries/admin staff
Most rejections I’ve seen came from nameless non clinical staff, as they can’t tell difference between carpal tunnel and degenerative/necrotic carpal bone, it’s all the same to them lot. Going to borrow the rejection of rejection approach.
Oh, and never accept shared care for ADHD meds. When you need partilaist/”specialist” advice – they will not be there.