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Primary-Secondary Care Interface

On-going work to implement the NHS Standard Contract

In 2015/16 NHS England recognised that general practices were being burdened with work that should be carried out hospital clinicians and administrators. As a result clauses were added to the NHS Standard Contract in 2015/16 and 2016/17 to compel secondary care trusts, hospitals and mental health, to carry out these administrative and clinical tasks.

The underlying principles behind these contractual changes are:

  • Clinicians must take responsibility for the care of patients they are looking after, and not delegate this responsibility to others
  • The pathway for the patient must be as linear and simple as possible

The relevant clauses within the Service Conditions of the NHS Standard Contract are:

  • 6.8 Accept all clinically relevant referrals- these should be made via eRS but do not have to in any specified format
  • 8.4 If the patient has need for further treatment “which is directly related to the condition or complaint which was the subject of the patient’s original referral or presentation” the specialist arrange for “the required treatment or care in accordance with this Contract, acting at all times in the best interest of the patient”- thus make onward referrals if needed
  • 11.3 and 11.4 Have appropriate shared care protocols and processes for high risk drugs, and not to transfer prescribing until the GP has agreed to “share care”
  • 11.5 Discharge summaries to be issued to patient and GP practice within 24 hours of discharge
  • 11.7 The Provider must send the Clinic Letter as soon as reasonably practicable and in any event within 7 days
  • 11.9 Following discharge provide a minimum of 7 days medication required by the patient
  • 11.10 Issue medication following outpatient attendance at least sufficient to meet the patient’s immediate clinical needs until their GP receives the clinic letter. (Clinic letters must be received within 7 days)
  • 11.11 Issue a Fit Note to the patient for the full period from incapacity through to anticipated recovery
  • 12.1.1 Arrange and carry out all necessary steps in a patient’s care and treatment promptly, this includes arranging investigation
  • 12.1.3 notify the patient of the results of all investigations and treatments promptly and in a readily understandable, functional, clinically appropriate and cost effective manner
  • 12.2.2 and 12.2.3 Respond to your patient’s recent query pertaining to their care – not ask the patient to contact their GP. Give your contact details to your patients when they attend clinic so that they can contact you with future enquiries
  • Trusts also have to have an Access Policy which describes how “Did Not Attend” is managed, and this cannot include a blanket policy for discharge, each case should be reviewed individually

NHS England has produced a useful summary of this information “Interface between Primary and Secondary care: Key messages for NHS clinicians and Managers”- https://www.england.nhs.uk/wp-content/uploads/2017/07/interface-between-primary-secondary-care.pdf

In 2019 the LMC audited contract compliance of local trusts, and found that in many circumstances the contract was not being complied with. Due to specialists carrying out remote consultations there has been a significant increase in inappropriate requests for practices to perform tasks which the contract stipulates are for secondary care to complete.

As a result LMCs across the country are reminding GPs and practices that they can and should request that these actions are carried out by the hospital teams.

BMA has also written to Prof Stephen Powis to request urgent support to enable technological solutions to enable hospital doctors to use e-prescribing and e-fit-notes.

If you identify that a secondary care specialist has not complied with these contractual obligations it would be helpful to remind them of their obligations. The letter attached above can be used to do this. When you send these letters please copy in the LMC and also your CCG locality lead.