PRIMARY-SECONDARY CARE INTERFACE
Nationally and Locally Agreed Protocols
Understanding what your colleagues in other organisations are contracted and able to provide can be difficult. We have summarised national and local guidance below, which should act as a reference for our hospital colleagues.
The following is a helpful PDF link of the key messages: https://www.england.nhs.uk/wp-content/uploads/2017/07/interface-between-primary-secondary-care.pdf
Contents
1) Referring A Patient Onwards
2) Discharging Patients From Clinics
3) Investigations In Secondary Care
4) Prescribing Over The Interface
5) Shared Care Protocols
6) Sick Notes
7) Further Support for Secondary Care Clinicians
1) Referring A Patient Onwards
When should a hospital clinician refer a patient for onward care, rather than ask their GP to do it?
Direct ‘consultant to consultant’ referral should automatically proceed in the following cases:
i) Further investigation of the referral complaint
Cases where further investigation of the presenting complaint is considered necessary in order to commence treatment but where these further investigations could not be conducted by the first consultant.
ii) Urgent Referrals
Conditions where referral back to the GP would have significant adverse effect on the clinical outcome for the patient. For example, for patients with suspected cancer (regardless of whether or not this was the reason for original referral to the hospital) or where delay would lead to an unacceptable delay in assessment and commencing treatment.
iii) Symptoms which are part of a recognised care pathway
Cases where the presenting sign or symptom automatically indicates that a patient would be managed within an agreed care pathway (either formally approved or accepted local best practice). For example, patients with carpal tunnel syndrome who have had the diagnosis confirmed with nerve conduction studies or rheumatology patients who need orthopaedic surgery.
iv) Referrals within a specialty for the same condition
Cases where it is obvious the referrer has sent the patient to the correct specialty but the wrong consultant should be forwarded to the correct clinician without the delay of sending the referral back to the referrer without charge to the Commissioner.
When you don’t need to refer onwards
The situation where a hospital clinician is not required to make on onward referral is if it is for a reason other than that for which the patient was referred, and the clinical need is not urgent. For example, a patient might consult with a clinician for a painful knee. At the time of the consult, the patient asks the clinician for an opinion on a troublesome rash which has nothing to do with the knee issue. In these circumstances, the clinician can reasonably ask the patient to consult their GP rather than refer to Dermatology.
GPs appreciate it when the hospital clinician does not unduly raise patient expectations of onward referral or testing.
“Ask your GP to assess that” is generally a better phrase than “Get your GP to refer you for [X]”. However, if the consultant believes a referral for an incidental condition is required, they should write to the GP with this recommendation.
If you have recommended your patient see their GP about an issue, ask the patient to book in with the GP, rather than ask the GP via letter todo this. This avoids the patient falling through the net and saves a significant amount of admin time.
2) Discharging Patients From Clinics
Where providers automatically discharge all patients who do not attend a clinic appointment back to their GP, this can create inconvenience and delays for patients and cause significant additional work for practices in simply re-referring many of the patients.
The standard NHS contract requires that a provider’s local access policy must not involve blanket administrative policies under which all DNAs are automatically discharged; rather, any decisions to discharge are to be made by providers on the basis of clinical advice about the individual patient’s circumstances.
Good practice in the event of a DNA without known reason or contact from the patient is to offer a one further appointment before discharging. Other scenarios should be decided clinically.
3) Investigations in Secondary Care
Ordering Tests
The hospital clinician should arrange and carry out all of the necessary steps in a patient’s care and treatment rather than, for instance, requesting the patient’s GP to undertake particular tests within the practice.
There is no funding in the national GP contract for GPs to provide a phlebotomy service. In the absence of local arrangements for funding, GPs either provide this out of their own profits, or refer the patient to the hospital phlebotomy service (which is funded). Similarly, GPs are not centrally funded to provide ECGs, spirometry, or a host of other tests and services.
Local arrangements:
As it is sometimes more convenient for a patient to have blood tests at their GPs, in some areas of BOB, commissioners have commissioned GPs to do blood tests on behalf of secondary care. These locally commissioned services are only for the patients who are both registered at a practice who has agreed to do this, AND with which the requesting hospital is a party to that agreement.
Oxfordshire: The hospital doctor wanting the blood tests done must order these on their hospital electronic notes system, print a paper copy of that request and give it to the patient prior to patient booking in for a blood test with their GP. It is not sufficient to tell the patient or GP in a clinic letter what tests they want done. GP phlebotomists use the printed blood request form to send the samples to the labs and the form ensures that the results can go back to the requesting specialist and not the GP. Without the hospital clinician providing the blood test form, the GP must order the tests themselves, they hold the medico-legal responsibility (which may be outside of their remit), they have to process and explain the results to patients themselves (additional appointments), and the whole process is unfunded in General Practice. GPs are within their contractual rights to decline to do blood tests for secondary care. This locally commissioned service is optional for practices.
East Berks, West Berks, & Bucks: The CCGs in these counties have not commissioned a service for GPs to do blood tests on behalf of secondary care. Hospital Clinicians in these counties should therefore order their own blood tests and make arrangements for their patients to have blood tests done in the hospital outpatients phlebotomy department.
Communicating the Results
The ordering clinician should communicate the results of investigations and tests carried out by the provider to patients directly, rather than relying on the practice to do so.
All clinicians, whether in primary or secondary care, retain clinical and medico-responsibility for the results of investigations which they personally request; sending a result on to another clinician does not absolve the original requester of that responsibility
This applies whether you are delivering elective or urgent/unplanned care. Results of tests ordered for a patient seen even briefly in acute care must still be chased by the ordering clinician and communicated back to patient if appropriate (for example, triple swab results for patients seen in the urgent gynae clinic). You should not ask the GP in a discharge summary to chase results.
Handling Patient Queries
Hospital clinicians should have efficient arrangements for handling patient queries, rather than simply passing them on to the GP to deal with.
4) Prescribing Over The Interface
Provision of insufficient quantity of medication from secondary care can mean that patients run out of medication, with adverse effects for their care, and have to make avoidable extra appointments with their GP, and the GP will not be able to prescribe appropriately if he/she has not received up-to-date information from the hospital about the patient’s care.
The standard hospital contract allows the period for which the provider must supply medication to be determined in a local policy, but this must at least cover a minimum period:
For medication on discharge following hospital admission, the minimum period is seven days (unless a shorter period is clinically appropriate).
Where a patient has an immediate need for medication as a result of clinic attendance, the provider must supply sufficient medication to last at least up to the point at which the clinic letter (or other such notification) can reasonably be expected to have reached the GP and the GP can prescribe accordingly (this is typically 5-7 days from receipt of notification).
Local Formularies
Local formularies are created by collaboration between specialists and local commissioners - so they are local, not national, and there is variation across the country. Where a hospital clinician is asking a GP to prescribe for a patient, they need to be mindful of the formulary that GP has to adhere to (i.e. which county they are in).
The Berkshire West Formulary can be found here: http://www.westberksformulary.nhs.uk/
The Berkshire East & Frimley Formulary can be found here: http://www.frimleyhealthformulary.nhs.uk/
The Buckinghamshire Formulary can be found here: http://www.bucksformulary.nhs.uk/
The Milton Keynes Formulary can be found here: https://formularymk.nhs.uk/
The Oxfordshire Formulary can be found here: http://www.oxfordshireformulary.nhs.uk/
Medicines in local formularies are typically divided up into six categories:
Red: Medicines which should only be prescribed in secondary care by a specialist
Amber: Medicines that may be recommended by a specialist and prescriptions and monitoring continued in General Practice. There are various sub-divisions of AMBER drugs that vary by region but, in summary, may include:
Amber Initiation: Amber medicines that must be initiated (i.e. first prescribed) by the specialist and the patient stabilised before handing over to the GP to continue prescriptions. The specialist must notify the GP that the prescribing responsibility has been transferred.
Amber Recommendation: Medicines which may be recommended by a specialist, but the GP may issue all the prescriptions, including the first one.
Amber Shared Care Protocol: Medicines which are appropriate to be initiated and stabilised by a specialist. Once stabilised it may be appropriate for responsibility for prescribing and routine monitoring to be transferred from secondary to primary care with the agreement of a GP via a a formal ‘shared care protocol’. The shared care protocol must be pre-approved by the local commissioner. See below for more details.
Green: Medicines which are suitable for initiation and ongoing prescribing within primary care.
Brown: Medicines which should only be prescribed in restricted circumstances.
Black: Medicines which are not recommended for use because of lack of evidence of clinical effectiveness, cost effectiveness or safety
Non-formulary: drugs which should not be prescribed. Patients who are currently on a non-formulary drug, but were started within the NHS before this formulary was published, should be able to continue treatment until they and their NHS clinician consider it appropriate to stop. If clinically appropriate patients on non-formulary drugs should be switched to drugs within the formulary.
GPs may punitive action, including loss of income, if they breach formulary guidance. As such, they will often decline to prescribe medicines listed in their local formulary as ‘RED’ or ‘Black”, regardless of whether or not the hospital clinician has requested it, or whether that hospital clinician is working in the NHS or private sector. If that hospital clinician still wishes their patient to have that medication, they may provide one-going prescriptions and relevant monitoring themselves.
5) Shared Care Protocols (SCP)
Some medications are subject to a shared care protocol (SCP). These are specialist medications that would normally be prescribed and monitored entirely within secondary care. However, specialists and commissioners have identified circumstances where, after initiation and stabilisation by the specialist, and with sufficient written and other guidance, the GP may continue to prescribe and monitor the medicine on behalf of the specialist. Methotrexate is an example of a medicine under an SCP.
A list of shared care protocols in each of the counties can be found using the formulary links above.
GPs are under no obligation to prescribe a drug that has SCP. NHS England lists a number of situations where a GP may decline to do so, which we summarise below and can found here. In these situations, the specialist must continue to prescribe and monitor the medicine themselves, until the problem is rectified and handover of care accepted, or for as long as the treatment is needed.
Legitimate reasons for a GP to reject shared care are as follows:
☐ Specialist has not provided sufficient contact details for communication when urgent advice is required
☐ Specialist has not provided sufficient clinical information about this patient’s condition
☐ Shared care has been requested without collaboration, counselling, and consent with the patient and/or carer
☐ Specialist has not initiated the treatment. Initiation of the medicine should be undertaken in secondary care
☐ The patient’s condition is not stable and predictable. This must be the case before shared care can be initiated
☐ Prescribing and managing this condition is outside of GP’s clinical competence and is outside of the competence of other prescribers in the Practice (as per GMC’s core guidance)
☐ There is no local shared care agreement for the drug, and current formulary guidelines prevent GPs from prescribing this medicine in primary care
☐ The request for prescribing falls into one of the following categories for which shared care is inappropriate because it involves a medicine:
undergoing or included in a hospital-based clinical trial
requiring specialist monitoring and ongoing specialist intervention
that is unlicensed; or are used off-label without an associated evidence base or being recognised as standard treatment
that is only available through hospitals
Patients receive the majority of ongoing care, including monitoring, from the provider and the only benefit of transferring care would be to provider costs
☐ The Patient has declined shared care after due consideration of the options, because they feel it is not in their best interests
☐ There are not sufficient resources in place for the GP to carry out the required monitoring
Hospital clinicians should only initiate care for a particular patient under a shared care protocol where the individual GP has confirmed willingness to accept clinical responsibility for the patient in question
6) Sick Notes
If the secondary care clinician, whether in out-patients or acute department, advises the patient is not fit for work, they should provide a sick note for the duration of anticipated absence from work, rather than ask the GP to provide this.
For example, it a surgical team reasonably expects a patient to be not fit for work for six weeks, they should provide a sick note for the entire six weeks rather than, say, giving two weeks and asking them to see their GP for a further issue.
7) Further Support for Secondary Care Clinicians
Interface issues can be complex and confusing. If you have further questions, then please do email us at assistance@bbolmc.co.uk and we will be happy to respond promptly. Please do not provide patient-identifiable information.
Last updated: 18 March 2021