Abstract
Due to the increasing pressures on General Practice services within the National Health Service, 1 the interface between primary and secondary care, and the division of labour between these, has become an important issue. This has long been an area prone to difficulties and conflict, the consequences of which can directly impact the quality and safety of patient care, particularly for patients with chronic conditions who regularly transition between these two sectors.2,3 This article explores the measures recently implemented in the NHS Standard Contract which aim to target common issues at the primary–secondary care interface, with an aim to reducing inappropriate General Practitioner workload in England. We will discuss the context behind the implementation of the NHS Standard Contract as well as current concerns and areas for further consideration.
Issues at the primary–secondary care interface
The crisis in General Practice caused by increasing workload coupled with a workforce that has not grown to meet this demand has been a national focus over the past few years. 4 A British Medical Association survey of General Practitioners in England found that 57% felt their workload was excessive and that this impacted on the quality and safety of care. 5 Research has shown that secondary care is a common contributor to this workload. A report, commissioned by the Primary Care Foundation, found that processing information from hospitals was the second most burdensome source of bureaucracy encountered by General Practitioners. The same report also found that demand created by hospitals was responsible for 4.5% of potentially avoidable General Practitioner appointments. Within this, the most significant contributing factor was problems with booking outpatient appointments (i.e. administrative errors or missed appointments resulting in the need for repeat referrals), accounting for 2.5% of avoidable consultations. 6
Dealing with patients who have missed an appointment has become a common source of frustration among primary care physicians. A 2015 article published in Pulse, a primary care news magazine and website, highlights the additional workload generated when a patient misses an outpatient hospital appointment. In these circumstances, patients are routinely told to make another appointment with their General Practitioner for them to send a repeat referral, even though their clinical condition remains unchanged since the initial referral. The authors note that an easy solution to this problem would be for patients to be able to contact the hospital directly to rearrange the appointment, something which would seem intuitive but which previously has often not been possible. 7
The Primary Care Foundation report found that an additional important contribution to avoidable workload is made by hospital staff advising patients to see their General Practitioner for the prescription of medication, interventions or test results that were part of their hospital care. 6 This echoes the views of the Royal College of General Practitioners which, in a recent paper, explained that General Practitioners across the country are too often being asked via hospital discharge summaries to arrange follow-up procedures, investigations and prescriptions. 8 A qualitative study conducted in Scotland in 2016 discusses a common theme of ‘dumping’, where primary care physicians felt they were being asked to perform tasks, such as follow-up of secondary care investigation results, without any discussion or resource allocation. 9 These findings collectively highlight a lack of clear division of responsibility for certain aspects of patient care at the primary–secondary care interface, as General Practitioners are simply directed to perform tasks by way of a discharge summary that ought to be performed as part of hospital care, without prior consultation. This contributes to an increased but potentially avoidable workload for General Practitioners.
This lack of clear division duty of care and poor level of communication between primary and secondary care can also impact on quality of patient care and safety. A qualitative study conducted in 2013 by Slight et al. 10 examined the causes of prescribing and drug monitoring errors in General Practice and found issues around the primary–secondary care interface to be an important theme. They cited delays in receiving, and often poorly written, discharge summaries as significant factors.
What has been done to address these problems?
The issue of hospitals adding to General Practitioner workload unnecessarily in the context of an already overstretched primary care service contributed to a formal report by NHS England, first published in April 2016. The General Practice Forward View set out a number of pledges to prevent hospitals passing on unnecessary and inappropriate work to primary care. It focused on preventing patients from being sent back to their General Practitioner for a re-referral if they failed to attend an outpatient appointment; being sent back to their General Practitioner from secondary care for an onward referral for a problem related to the original referral; and the failure of secondary care to provide General Practitioners with adequate information about inpatient treatment, investigations and medications.
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This led to the inclusion of clear national requirements in the NHS Standard Contract for England that secondary care providers must follow to prevent unnecessary workload for General Practitioners. This was introduced in April 2016
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and later updated in 2017 to include six further requirements.
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A summary of the key messages in latest version of the NHS Standard Contract can be seen in Figure 1.
NHS Standard Contract 2017/18: summary of the key messages.
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Has the NHS Standard Contract been successful so far?
Despite the implementation of this contract in 2016, concerns continue about its success in reducing unnecessary workload. So far, no substantial evidence evaluating the impact of the contract exists, but a freedom of information request sent by Pulse magazine to 93 clinical commissioning groups found approximately 3600 complaints from General Practitioners about breaches to the contract. Moreover, despite these complaints, not a single sanction had been issued against hospitals. 15
This lack of compliance is concerning and may be due to the lack of effective mechanisms for enforcing the contract’s provisions. Currently, there are no positive incentives for hospitals to adhere to the contract, as the mechanisms in place to enforce the contract rely on General Practitioners pushing back inappropriate workload by sending letters, reminding the recipients of their duties under the new contract. They also rely on General Practitioners to report breaches to the local clinical commissioning group and to keep a record of these to report to the Local Medical Committee (the body which negotiates on behalf of General Practitioners with local NHS Standard Contract commissioners) each month. 16
The current enforcement mechanisms, therefore, increase the administrative workload for General Practitioners and their practices, as they alone are responsible for sending the appropriate paperwork, keeping records and reporting on breaches. Conversely, there appears to be little in the way of real sanction for hospitals which fail to comply and no positive incentives for them to change their behaviour. Moreover, these enforcement mechanisms are unlikely to encourage cooperation between primary and secondary care: it is not difficult, for example, to imagine how the process of sending of tersely worded letters (see Figure 2 for a template letter) from General Practitioners to hospital doctors, and the bouncing of work back and forth could unintentionally lead to increasing tensions between them, instead of fostering a culture of collaborative working.
Template response letter for missed appointment.
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Limitations of the NHS Standard Contract
One possible contributing reason for this limited compliance within secondary care could be a lack of knowledge of these new contractual requirements among junior hospital doctors. These are the team members who are usually responsible for issuing discharge summaries, discharge medication and fit notes, all of which are responsibilities highlighted in the NHS Standard Contract hospital contract. Although little research has been done into the knowledge of the requirements laid out in the new contract among junior doctors working in secondary care, the issuing of discharge paperwork is historically an area where they receive little training. An audit conducted in Plymouth Hospitals NHS Trust in 2011, for example, focusing on sick note certification found that 54% of junior doctors were unaware of which certificates are commonly issued in hospitals. 17
As with primary care, there is also an increased workload among hospital doctors, with increasing vacancies and numerous rota gaps resulting in an overburdened secondary care workforce. 18 This is likely to be a significant contributing factor to the current lack of compliance with the requirements laid out in NHS Standard Contract. The contract relies on hospitals taking on more responsibilities without allocation of any additional resources or positive incentives, further increasing pressures on secondary care teams. This is something that the NHS Standard Contract currently fails to consider and which should be rectified; for example, through financial incentives to support the implementation of the contract.
What else needs to be done?
These findings highlight the need for further changes to be made to help tackle the current crisis in General Practice and eliminate inappropriate workload. One solution that could easily be implemented is to deliver training to junior doctors on the relevant points highlighted in the NHS Standard Contract during their hospital inductions. Another solution would be to include more General Practice placements in the foundation training of junior doctors. This would give more of the NHS Standard Contract medical workforce an insight into the difficulties encountered in General Practice, which could in turn encourage more cooperation at the primary–secondary care interface when these doctors move to subsequent secondary care placements. Systems-based interventions could also be used to improve the primary–secondary care interface. One of these would be to give hospitals in England access to the NHS Electronic Prescription Service. The Electronic Prescription Service is a system that allows prescriptions to be sent electronically from General Practitioner surgeries to pharmacies, thereby making the prescription process more efficient and less time-consuming for General Practitioners and safer for patients. 19 Currently, this system is only accessible to General Practitioners, which means that hospital doctors must issue separate printed or handwritten prescriptions which then must be given to the patient. If hospital doctors had access to the Electronic Prescription Service, for example, if a wound swab or urine sample showed an infection in a patient who had been recently discharged from hospital, a hospital clinician could contact the patient and send a prescription electronically to a pharmacy of the patient’s choice, instead of requiring the General Practitioner to do this on their behalf. This would free up valuable time for General Practitioners, as well as being more convenient for patients.
Another potential system-based solution would be to make hospital-issued fit notes available in an electronic format. Currently, they are paper-based in many hospitals, making them difficult to locate on busy wards and often time-consuming and inconvenient to fill out. If they could be completed and issued electronically along with the patient’s discharge summary, which could also be formatted to include a fit note prompt, this would make this process much more convenient for hospital doctors, thereby increasing compliance with this contractual requirement. These system-based changes, in combination with the NHS Standard Contract, could help relieve some of the extra burden that is currently being placed on primary care services by hospitals.
Conclusion
The current crisis in primary care means the NHS Standard Contract is needed to clearly define responsibilities between primary and secondary care. However, initial experiences and anecdotal evidence suggest that these standards are not currently being rigorously enforced, resulting in little beneficial impact for General Practitioners, their teams and for patients. Further research is needed to fully understand whether the NHS Standard Contract has been successful in achieving its aims and, if not, how best to address this.
Although improving the timeliness of clinic letters and discharge summaries to facilitate communication, and a clearer division of work and responsibilities at this interface is necessary, an important aspect to consider is that hospital doctors need to be equipped with a greater awareness of the present challenges faced by General Practitioners. Hospitals also need to be given some positive incentives for meeting the aims set out in the NHS Standard Contract. These changes could then help improve working relationships between General Practitioners and hospital doctors, and thereby reducing inappropriate General Practitioner workload and improving patient experience in the NHS Standard Contract in England.