The four-member practices that form Belper PCN have agreed on the below policy to support our General Practice workload. It sets how we, Belper PCN look to approach inappropriate workload requests from other providers with example scenarios included.

 This guidance has been written In line with the BMA workload control strategy that enables General Practice to improve quality and safety for our patients. The PCN supports using this policy in our member practices, Arthur Medical Centre, Riversdale Surgery, Appletree Medical Centre, and Whitemoor Medical Centre.  It also applies to services provided directly by Belper PCN.

Due to the broad scope of the care provided by general practice, the aim is to guide our clinicians and practice colleagues, with suggested tools they can use to achieve workload control. Any workload requests not covered by this document or where the application of the BMA guidance is ambiguous will be discussed by the PCN Clinical Directors and PCN Clinical Quality Manager for a consensus view.

Belper PCN is committed to keeping positive working relationships with our colleagues in other providers, including in secondary care and private healthcare. We fully appreciate and acknowledge the significant challenges they meet. However, we cannot take on additional work from other providers as doing so would detract from our responsibility to provide safe, high-quality care.

General Practice has been receiving increasing requests for referrals, tests, prescriptions, and other requests for work/action from the practice by other providers.

Inappropriate transfer of work into the practice/PCN can potentially use many resources affecting our team's ability to care for our patients.

We recognise the current challenges facing the NHS, including long waiting for appointments, access issues, and an increasingly complex system and with a greater number of care providers, these are all contributing to these requests. These factors are largely beyond the control or influence of the practices and PCN, however, we will continue to advocate for better patient care across the NHS system where opportunities allow

1. Requests for Referrals
2. Requests for Investigations
3. Requests for results for tests arranged elsewhere (or interpretation)
4. Requests for follow-up care
5. Requests to speed up appointments.
6. Requests for letters (including schools)
7. Prescription requests are dealt with in our separate prescriptions/medication guide.

All services can arrange onward referrals and it is inappropriate for these requests to come back to the practice. This includes:

• Referral between hospital specialists
• Referral for ongoing out-patient care following hospital admission or Emergency Department attendance.
• Referral from private providers to NHS services

When these requests come to us in a letter, we will send a standardised response to the sender asking them to arrange the referral.

When the request is made directly by the patient (following the advice of an external clinician) the patient will need to contact the relevant clinician.

Sometimes other clinicians may share with us their opinion or recommend that a referral be considered. In this scenario, the practice oversees the ongoing care & the decision of whether to refer still is with the practice team. For a referral to be considered, a review (by the practice team) is needed to assess the problem and to plan the right management. It is likely an appointment will be needed for this.

Example:

The patient is seen in the ED for chest pain. The decision is made that reflux was the probable cause & treatment is started. GP asked to consider referral to gastroenterology if symptoms were not controlled. Medications issued don’t help and the patient books an appointment with practice to consider the next steps.

BMA guidance: "Managing onward referrals- Clinicians working for the provider should make an onward outpatient referral, without needing to refer back to the GP, where it is directly related to the condition for which the original referral was made, or the patient has an immediate need for investigation or treatment."

https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/primary-and-secondary-care/primary-and-secondary-care-working-together

All services handle arranging their investigations (e.g., blood tests or scans). It is inappropriate for other services to request the practice arrange these. This includes:

• Investigations for hospital specialists
• Investigations for follow-up tests following a hospital admission or assessment at an acute service e.g., ED.
• Investigations for private providers
• Exception for out-of-area NHS providers – see below.

When these requests come to us in a letter, we will send a standardised response to the sender asking them to arrange their investigations.

When the request is made directly by the patient (following the advice of an external clinician) the patient will need to contact the relevant clinician.

Sometimes other clinicians may share with us their opinion or recommend that an investigation be considered. In this scenario, the practice decides whether the investigation is appropriate, whether we are the right people to arrange it, and if we have the skills to interpret and action the results. This normally requires a review in an appointment.

Patients who choose to have their care provided by a private provider will be treated in the same way as those receiving NHS specialist care. We are unable to arrange investigations on behalf of private specialists to reduce the patient's costs.

Post-discharge – If following an admission, the patient is not staying under the hospital team as an out-patient it may be right for the hospital to ask us to repeat blood tests to ensure resolution of an issue or to continue monitoring medications on their repeat prescription. This will be communicated in the discharge summary to us. Inappropriate requests will be communicated back to the discharging team.

Exception – sometimes service users may need the input of a highly specialist NHS service not available in the local area. For example, ongoing care under a regional transplant team. We will consider arranging and communicating investigations on behalf of the specialist in these scenarios (This exception is because it would be unreasonable to ask the patient to travel for a test available locally & because the current IT systems prevent out-of-area teams from requesting tests local to the patient or accessing the results).  We are not contracted or obliged to do this work and will consider requests on a case-by-case basis.

Examples:

1. Patient seen in orthopedic clinic for knee pain. The orthopedic surgeon asks the practice to arrange an x-ray of the knee. This investigation is best arranged and interpreted by the specialist.

1. The patient is admitted with a chest infection.

Found to have an abnormal chest x-ray. Repeat x-ray needed to ensure lungs are clear after antibiotics. Directly relevant to admission and hospital investigations - Discharging team to arrange and action results.

Low sodium levels on discharge, requested by the hospital for blood test two weeks post discharge – agreed right as part of General Practice community/continuing care and right to ensure safe monitoring of medications and medical condition.  

1. Patient decides to see a gastroenterologist privately about their bowel symptoms due to long waits on the NHS. The gastroenterologist recommends blood tests to decide the cause of the symptoms and a follow-up appointment. The private provider needs to arrange this blood test & interpret the results.

BMA guidance: " Communicating with patients -Providers should put in place and publicize arrangements for handling patient queries. Providers should communicate the results of investigations and tests to patients directly."

BMA guidance:

The requesting clinician is responsible for communicating test results back to the patient and arranging any actions or follow-up.

Results go back to the requesting clinician. Hospital test results are not routinely visible in the practice's patient records.

Any tests or investigations that patients arrange privately without the oversight of a clinician competent to interpret and action them remain the patient's responsibility.

Example:

The patient decides to arrange private blood tests advertised as a well-person check.  The blood tests find an abnormality, but the company cannot act or interpret this for the patient. It is the patient's responsibility to find a private provider to do this.

BMA guidance: "Communicating with patients -Providers should put in place and publicize arrangements for handling patient queries. Providers should communicate the results of investigations and tests to patients directly."

https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/primary-and-secondary-care/primary-and-secondary-care-working-together

Follow-up care post-discharge from other services.

• Once an episode of care with a specialist has been completed patients will be discharged back to primary care. The practice will then supply any ongoing monitoring or medications (provided this is within the scope and experience of the practice team).

Shared care agreements - this is a treatment-specific agreement between primary and secondary care that sets out the role of each organization in prescribing and monitoring that medication. It is used for specialist treatments that primary care doesn’t initiate. The practice can enter shared care agreements with private providers and will consider doing so provided the roles of each are clearly defined, there is a clear route for communication should any issues be identified by the practice, the specialist is happy to resume responsibility for providing the treatment if there are any issues with the agreed monitoring and an equivalent service would be available on the NHS. All shared care agreements with NHS and private providers are entered into at the discretion of the GP practice, there is no obligation on the practice to enter into  shared care.

Follow-up care following surgery or treatments abroad:

• The practice or PCN is unable to supply ongoing monitoring or arrange follow-up for patients if they have chosen to have treatments abroad.
• The patient handles sourcing a provider to continue the care once back in the UK.
• The practice/PCN can then take over any ongoing monitoring or medications once the condition is stable (normally at an equivalent point to when care would be transferred in the NHS) & providing that there is proper specialist support for any issues.

Examples:

A patient with rheumatoid arthritis sees a private rheumatologist. It is recommended they start an immunosuppressant medication for this. This treatment is available on the NHS. The specialist starts the medication and ensures the patient is stable on it before asking the practice to take over the monitoring (clear guidance available) and supplying the prescriptions under a shared care agreement.

A patient decides to have weight loss surgery abroad. Immediately following their surgery, they return to the UK and request blood tests and dietary support. The practice team does not have the skills and experience to manage the patient in the post-op period and the patient needs to source this privately. After two years their condition is stable & they have reached the usual point where care would be transferred to the NHS, the practice/PCN is then able to take on the ongoing annual monitoring and prescribe the vitamin supplementation as suggested by the specialist team.

We understand that the long waits patients are currently facing are frustrating, but the practice team/ PCN is unable to speed up appointments with other providers.

If a patient's symptoms have changed or deteriorated, they can contact their specialist, usually via their secretary, to inform them of any changes and to communicate their concerns.

If a patient becomes unwell, they should contact the practice in the usual way.

Below is a letter template that patients can complete to update their specialist of any changes whilst they are waiting for their clinic appointment, treatment, or surgery.

Letter for a first appointment with a specialist (suggested letter wording for patients to use):

We often receive requests for letters or reports from patients, common examples include:

• Medical & medication summaries
• Letter of fact to support applications e.g. for housing.
• Fit to fly letters.

This is not NHS work, and our team undertakes this work in their own time. The practice or PCN charges for this work. A document outlining charges made is accessible on our PCN/Practice Webpage.

External organisations who require medical information should be encouraged to seek patient written consent and then contact the practice directly. They often have specific forms they ask us to complete to ensure all the required information is gathered. This work is often invoiced to the other organisation directly (e.g., DVLA or DWP) occasionally a patient may be asked to pay for it upfront and then claim it back elsewhere if appropriate (e.g., travel insurance forms). Examples include:

• DWP – department of Work and Pensions (e.g for benefits assessments)
• DVLA
• Travel Insurance claims.
• Critical illness claims

Schools:

We are unable to give opinions on whether school absence was proper and will not authorise or write in support of absence from school.

 If a child's education provider requires medical information from the practice, they should contact us directly (with the parent/guardian's written consent).

In most situations, education providers should be able to obtain the information they need from parents/guardians and our input should not be necessary.

We will supply medical facts and dates to schools on receipt of a direct written request from an education provider. We require parent/guardian consent to do this unless a safeguarding concern or other reason means that releasing the information is in the best interests of the child. A case-by-case decision will be made on whether these requests fall within NHS care or whether it is private work (and payment will be needed).

For common infectious childhood illnesses, the NHS advice on school attendance should be followed. https://www.nhs.uk/live-well/is-my-child-too-ill-for-school/

Resources used by the practice, BMA advice: https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/pushing-back-on-inappropriate-workload

 Another Alternative may be to have a generic template that simplifies the standard response, for example:

 This is a response to your correspondence of ( date )

In accordance with BMA and NHS England guidance Belper PCN practices are unable to make referrals, request investigations, or follow up test results for other providers.

Responsibility for carrying out the requested actions remains with you and has not been transferred to the practice.