Safe Working and Pushing Back on Workload Transfer
Page Contents
Pushing Back on Workload Transfer
Breaches to Standard Hospital Contract
Regulation Update 2023 – Access
The BMA has produced letter templates to help GP practices push back on inappropriate workload from ICBs, prescribers, hospitals and your area team.
Pushing Back on Workload Transfer
It is crucial that GPs and practices devote their time and energy to providing services and care that are commissioned and resourced. BMA has produced guidance with key headlines on how you might push back on un resourced work
Breaches to Standard Hospital Contract
Following lobbying by GPC, NHS England have added the following requirements to the hospital standard contract as of 1 April 2016:
- Local Access Policies
Hospitals cannot adopt blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for re-referral. Hospitals must publish local access policies and demonstrate evidence of having taken account of GP feedback when considering service development and redesign.
- Discharge Summaries
Hospitals are required to send discharge summaries by direct electronic or email transmission for inpatient, day case or A&E care within 24 hours, with local standards being set for discharge summaries from other settings. Discharge summaries from inpatient or day case care must also use the Academy of Medical Colleges endorsed clinical headings, so GPs can find key information in the summary more easily. Commissioners are also required to provide all reasonable assistance to providers in implementing electronic submission.
- Clinic Letters
Hospitals to communicate clearly and promptly with GPs following outpatient clinic attendance, where there is information which the GP needs quickly in order to manage a patient’s care (certainly no later than 14 days after the appointment). For 2017/18, the intention is to
strengthen this by requiring electronic transmission of clinic letters within 24 hours.
- Onward Referral of Patients
Unless a ICB requests otherwise, for a non-urgent condition directly related to the complaint or condition which caused the original referral, onward referral to and treatment by another professional within the same provider is permitted, and there is no need to refer back to the GP. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
- Medication Following an Outpatient Appointment or On Discharge
Providers to supply patients with medication following an outpatient appointment or discharge from inpatient or day case care. Medication must be supplied for the period established in local practice or protocols but must be for a minimum of seven days (unless a shorter period is clinically necessary).
- Results and Treatments
Hospitals to organise the different steps in a care pathway promptly and to communicate clearly with patients and GPs. This specifically includes a requirement for hospitals to notify patients of the results of clinical investigations and treatments in an appropriate and cost effective manner, for example, telephoning the patient.
It is estimated that 15 million GP appointments, staff time and expense is wasted each year due to these inappropriate demands and workload shift onto GP practices.
NHS England and NHS Improvement wrote a reminder letter to all hospital providers to ensure adherence to these new requirements.
Our new template letters are designed to empower practices to demand that hospitals honour these contract changes, in order to relieve some of the daily bureaucratic burdens on GP practices.
Safe Working
Practices are encouraged to continue to use all other resources in the Safe working guidance, The guidance outlines how to manage workload effectively, setting safe limits of 25 patient consultations per day in line with UEMO recommendations, and encouraging practices to adopt systems that protect both patients and staff. As there is currently no standardised triage system for GP practices, to help with the increasing workload, the BMA have developed a tool to support practices with implementing a triage system if they wish to do so – this is also included in the guidance.
It also includes links to template letter resources (Appendices 1-11) to help you safely manage practice workflow and triage.
Practices can adapt the templates to suit their policies on such issues. We would suggest that the impact on the doctor/patient relationship is also considered when making decisions and patient vulnerabilities are also considered.
Regulation 17 Guidance
There is guidance for LMCs and practices on the interpretation of Regulation 17, and in particular, whether ICBs can determine what services fall within the definition of ‘essential services’ in the standard GMS contract and demand that GP practices provide those services.
Regulation Update 2023 – Access
It is also worth noting the 2023 update to the GMS Regulations around access. The NHSE letter says that it “will make clear that patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time”. The BMA/GPC England say that whilst they agree with the aspiration of this amended regulation, it believes that this requirement is not achievable for many practices with current resource and workforce. We would strongly recommend that you look at this requirement in more detail on the BMA’s GP access: meeting the reasonable needs of patients webpage. It highlights what the regulations will now say and also how this may affect safe working guidance.
Our contract states that we must meet the ‘reasonable needs’ of our patients. This is a very open-ended statement. We also have a responsibility to our staff, patients, and ourselves to work safely within our competence as per GMC guidance.
It’s for each practice to decide what is a reasonable number of appointments to safely offer, at which point all but the most urgent cases may have to be asked to wait for an appointment if they are able to (just like they do in secondary care) or be directed to seek advice or support from another service such as 111, NHS website, Wessex Healthier Together website, local pharmacy, MIU or A&E where appropriate. We would have to inform patients that we are effectively on an emergency footing because of unprecedented demand. There will always be those truly urgent cases that need seeing as an extra. The difficulty is that it puts additional pressure on our reception staff to police the access.
It may be that at times of high demand we have to sacrifice routine appointments to meet on the day demand. The risk with this is that our contract will penalise us if we don’t meet QOF targets etc. This is one of the reasons why we are pushing for target-based contracting to be excluded or dramatically and pragmatically reduced in any new contract.
If you are required to adopt an emergency footing, we would suggest you inform the ICB and your patient participation group.
Rebuilding General Practice
This campaign is funded by the GPDF on behalf of the general practice community.
General practice should be at the heart of every community – keeping patients safe and providing strong foundations for the rest of the NHS. But decades of neglect have broken the entire system. We don’t have enough family doctors to treat our patients. GPs are leaving the profession in droves and practices are closing all over the UK. Patients should be able to see us when they need to.
Our colleagues across the NHS should be able to work closely with us to provide the right care at the right time. A strong general practice keeps people healthy and gives them the care they need in their community. And it takes the pressure off hospitals and specialist services, saving money in the longer term.
Reform takes time, but these problems are immediate and real.
That’s why we need to come together and Rebuild General Practice. It is the only way we can keep our patients safe and protect the NHS.
Please visit Home | Rebuild General Practice for more information.
Other Useful Resources
Introducing a Safe Working 3 – Session Day for GPs
The Grove Medical Centre have reorganised its 12 GPs into two teams to improve patient care continuity, appointment availability and manage workload.
The practice now runs a 3-surgery block system per day rather than the traditional 2 sessions per day. Each block is nominally 4 hours 10 minutes long, starting at 8am, 12 midday and 4pm. There are between 7 and 9, 15-minute appointments per block. GPs choose how many blocks to work as long as the team covers the minimum number of blocks that the practice has agreed it needs to offer to deliver safe care.
Despite successes, challenges remain in balancing workload, patient satisfaction, and financial constraints. However, there has been a distinct improvement with not only ‘ownership’ of patient care but also communication between GPs, the team and whole practice ethic and as a result working closer together across teams improved. Camaraderie has grown in the practice and a more supportive ethos has evolved as a result.
Read the full case study in more detail here
Wessex Guidance pages on:
Wessex Safe working Podcasts:
With thanks to the BMA/GPC for their support and shared materials