The practice has been receiving an increasing number of requests for referrals, tests, prescriptions, and other requests for work / action from the practice by other providers.
Inappropriate transfer of work into the practice has the potential to use a large amount of practice resource affecting our teams ability to care for our patients.
We recognise that some of the current challenges facing the NHS including long waits for appointments, access difficulties, an increasingly complex system with a greater number of care
providers are contributing to these requests. These factors are beyond the control or influence of the practice team.
Arthur Medical Centre wants to maintain good working relationships with our secondary care and private colleagues, whom we value enormously and recognise the huge demands they also face. We simply do not have the capacity to accept additional transfer of work inappropriately from other providers and to do so would be to the detriment of our core role in the provision or primary care medical services.
The aim of the information below is to clarify how Arthur Medical Centre intends to respond to requests that involve the transfer of work or care from other providers to the practice.
It is based on the guidance provided by the BMA (British Medical Association).
Because of the broad scope of the care provided by general practice this information aims to ensure all patients are treated fairly and that the BMA guidance is applied in a consistent manner. Any requests not covered by this document or where the application of the BMA guidance is ambiguous will be discussed by the clinical team for a consensus view (this will be at the next suitable meeting, we are unable to do this urgently and the other provider will need to continue providing any urgent care until this is done). https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/primary-and-secondary-care/primary-and-secondary-care-working-together
Common requests for transfer of work
These requests may come from other parts of the NHS including secondary care or private providers:
Prescription requests are dealt with in our separate prescriptions / medication guide.
Requests for Referrals
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 A&E attendance
- Referral from private providers to NHS services
When these requests come to us in a letter we will send a standardised response back 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 is considered. In this scenario the practice is responsible for the ongoing care & the decision of whether to refer remains 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 appropriate management. It is likely an appointment will be needed for this.
Example:
Patient is seen in A&E regarding chest pain. The decision is made that reflux was the likely cause & treatment is started. GP asked to consider referral to gastroenterology if symptoms not controlled. Medications issued don’t help and patient books appointment with practice to consider next steps.
Requests for Investigations
All services are responsible for arranging their own investigations (e.g blood tests or scans). It is inappropriate for other services to request the practice arranges these. This includes:
- Investigations for hospital specialists
- Investigations for follow up tests following a hospital admission or assessment at an acute service e.g A&E
- Investigations for private provides
When these requests come to us in a letter we will send a standardised response back to the sender asking them to arrange their own 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 is considered. In this scenario the practice is responsible for deciding whether the investigation is appropriate, whether we are the appropriate people to arrange it and whether 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 remaining under the hospital team as an out-patient it may be appropriate for the hospital to ask us to repeat blood tests to ensure resolution of an issue or to continue monitoring medications on your repeat prescription. This will be communicated on your discharge summary to us. Inappropriate requests will be communicated back to the discharging team.
Examples:
A. Patient seen in orthopaedic clinic for knee pain. Orthopaedic surgeon asks practice to arrange an x-ray of knee. This investigation is best arranged and interpreted by the specialist.
B. Patient is admitted with a chest infection. Found to have an abnormal chest x-ray. Repeat x-ray required to ensure lungs are clear after antibiotics. Directly relevant to admission and hospitals investigations. Discharging team to arrange and action results. The patient is also found to have low sodium levels on blood tests during chest infection. Needs a repeat 2 weeks after returns home to ensure bloods normal and no changes needed to their regular medications. Part of ongoing community care – GP practice will arrange.
C. Patient decides to see a gastroenterologist privately about their bowel symptoms due to long waits on the NHS. The gastroenterologist recommends some blood tests to determine the cause of the symptoms and a follow up appointment. The private provider needs to arrange these blood tests & interpret the results.
Exception for out of area NHS providers – sometimes patients may require 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 prevents out of area teams requesting tests local to the patient or accessing the results).
Requests for Test Results
It is the responsibility of the requesting clinician to communicate test results back to the patient and to arrange any appropriate 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 patients responsibility.
Example:
Patient decides to arrange private blood tests advertised as a well-person check. The blood tests identify an abnormality but the company are unable to action or interpret this for the patient. It is the patients responsibility to find a private provider to do this.
Requests for Follow On Care
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 be responsible for providing 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 which clearly sets out the role of each organisation in prescribing and monitoring that medication. It is used for specialist treatments which primary care don’t initiate. The practice is able to 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.
Follow up care following surgery or treatments abroad:
- The practice is unable to provide ongoing monitoring or arrange follow up for patients if they have chosen to have treatments abroad.
- The patient is responsible for sourcing a provider to continue the care once back in the UK
- The practice 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) & provided there is appropriate 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 providing 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 expertise 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 in the NHS, the practice are then able to take on the ongoing annual monitoring and prescribe the vitamin supplementation as advised by the specialist team.
Requests to Expedite (Speed Up)
We understand that the long waits patients are currently facing are frustrating, but the practice team is unable to expedite appointments with other providers.
If your symptoms have changed or worsened you can contact your specialist, usually via their secretary, to inform them of any changes and to communicate your concerns.
If you are more unwell please contact the practice in the usual way.
We have also provided a letter templates 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
Letter for a follow up appointment with a specialist
Requests for letters
We frequently 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 work is not considered NHS work and our team undertake this work in their own time. The practice charges for this work and we take payment upfront for any requests.
If you require a private letter or statement from the practice please supply us with as much detail about what is required as possible. We are generally unable to do this work on an urgent basis. We can provide computer generated medical summaries and medication lists free of charge.
External organisations who require medical information about you will generally seek your 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 you 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 given opinions on whether school absence was appropriate and will not authorise or write in support of absence from school apart from in exceptional circumstances (e.g an immunosuppressed child having cancer treatment).
If your child's education provider requires medical information from the practice, they should contact us directly (with your written consent).
In most situations education providers should be able to obtain the information they require from parents / guardians and our input should not be necessary. (It should not be necessary for example for us to confirm medical causes for short absences).
We will provide medical facts and dates to schools on receipt of a direct written request from an education provider. We would require your consent to do this unless there was a safeguarding concern or other reason why releasing the information was 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 required).
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/
Prescribing over-the-counter medicines in nurseries and schools
GPs are often asked to prescribe over-the-counter medication to satisfy nurseries and schools. This is a misuse of GP time, and is not necessary.
Non-prescription or over-the-counter medication does not need a GP signature or authorisation in order for a school, nursery or childminder to give it. More information on this can be found by clicking here.