‘Advice and guidance is eroding our long-term contract with secondary care’

Nottinghamshire LMC wrote to the local trust about the implementation of a controversial advice and guidance scheme. Below is an abridged version of the letter

We write in response to proceedings held at the Nottingham City Council Health Overview and Scrutiny Group last Thursday, 14 July 2022, which is a result of weeks of concerns being expressed by GPs and patient groups about a significant service change adopted by Nottingham University Hospitals Trust (NUH) in managing their waiting list in the neurology department.

This article published last week by ‘The Doctor’ magazine, an in-house BMA publication provides details of what happened

The impact of moving to an ‘Advice and Guidance’ approach

The imposition of an ‘Advice and Guidance (A&G)’ as a virtual triage method of dealing with GP referrals has increased both the workload onto practices and transferred clinical risk from the speciality that is resourced precisely to manage such patients. There is also the risk that by not seeing the patient in an outpatient setting that there is further workload shift as the neurology department advises GPs to refer patients elsewhere in the hospital, which under the Standard NHS Contract is the responsibility of the hospital to manage internally – consultant to consultant transfers of care.

NUH refers to this change as a ‘virtual triage system for outpatient referrals’ and the approach was supported by the CCG as it was known at the time.

Talking to Peter Blackburn for ‘The Doctor’ magazine, local GP Dr Irfan Malik said ‘We only refer when we absolutely have to, but more and more referrals are being rejected with advice and patients not seen. Every referral is becoming a battle and a struggle – they send a letter back with lots of advice and things to do and other referrals to make. The patients are getting stuck and they still have the problems they initially had.’

A&G used to be there to address queries from GPs managing patients about a given presentation and help them to make the right decision about whether to refer or proceed differently. Many GPs found this to be very helpful and valued it greatly, in our view it is now being misused. It is now being used as a proxy for an outpatient appointment in many cases which has many deliberate or unintended consequences.

Traditionally, when GPs make an onward referral, they are usually saying to the patient and themselves that they have reached the limit of their own ability and expertise as GPs. It is now up to secondary care to look after the patient and manage what investigation they require to make the diagnosis and treat the patient accordingly. Ultimately that long-term model and contract that we have with secondary care, which has worked well for a long time, is being eroded to the detriment of our patients.

Passing resonsibility

We have an example of this new virtual triaging in action. A local locum GP in a Notts practice has this week received advice and guidance from neurology asking for numerous blood tests, possible scan and then a request to complete a proforma for a virtual headache clinic. It’s going to take considerable time and the patient will need to be called for a follow up GP appointment, for an appropriate explanation by a GP who is not the expert in this field. The GP receiving the advice hasn’t heard about this blood test and doesn’t know how to interpret the result.

This is clearly not advice and guidance; it is passing on the responsibility for secondary care work and patient communication in an irresponsible way that has not been agreed with the profession, that cannot be referred to as shared care.  GPs are independent experienced expert generalists and not house officers or admin clerks who act as a sink hole for un-resourced misdirected work. 

Dr [Jonathan] Evans, neurology consultant at NUH said at the health meeting last week: ‘Effectively when we are returning a referral with advice and guidance, assuming that’s what happened rather than a request for more information, we are passing responsibility back to the GP’ so this is a known shift of responsibility.

Integrated care agenda and professionalism

At the health overview and scrutiny group, [Dr] Evans stated that ‘It’s not for me to manage the workload of GPs, I have patients telling me it’s easier to see a neurologist than it is to see a general practitioner, read into that what you will.’ We consider this type of comment and the mindset that underpins it to be of serious concern.  Quite why such comments are made is hard to fathom if we are all trying to serve patients and move away from self-serving silo-working and achieve joined-up care with whole-system benefits. Even though the front-facing strap lines to justify this type of ill-designed system may be badged as being altruistically patient-centred, it seems that the true motive may be to meet financial waiting list targets and divert workload from an insufficient secondary care workforce. 

Many patients who would have been seen by the neurology department previously are now being sent back to the GP with ‘advice’ so this comment is nonsensical and unhelpful at best and disrespectful at worst. 517, 125 GP appointments were conducted in May 2022 across Nottinghamshire, a county with a population of over 800,000.  More GP appointments were conducted than in any time in history which has contributed to increasing our nation’s GDP – context is important when quotes are picked out of speeches and writing, but words and tone are equally important.

Summary

1. Virtual triage by neurology at NUH needs a rethink as the current process causes unacceptable and unsustainable workload shift, transfer of clinical risk and inappropriately forcing GPs to discuss specialist care plans with patients that they don’t own or at times even fully understand. This can create unnecessary delay and much confusion for patients and contributes to falling standards of quality.
2. Inter-professional respect is crucial if an integrated care system is to be productive; this works both ways. Relationships underpin systems and culture trumps strategy.
3. The LMC represents general practice. This is what we do. Utilise our knowledge and experience and we will ensure that we get the broadest engagement across the profession.  We want to improve the mechanisms by which general practice contributes to service design and transformation as we always place the patient at the centre of everything that we do. 
4. Please work with us so we can collaboratively achieve our collective endeavours and produce whole-system benefits.

Michael Wright

LMC chief executive                                                                                  

Dr Carter Singh MBE

LMC chair