Primary-Secondary Care Interface
We have summarised national and local guidance below, which should act as a reference for all colleagues in Primary and Secondary Care, and other NHS organisations.
Primary & Secondary Care Interface issues can be complex and confusing. If you have further questions, that have not been answered here, please do not hestiate to contact us at firstname.lastname@example.org
The NHS Standard Contract supports the aims for partners across the NHS healthcare system to improve communication, collaboration and working practices.
The following links provide helpful information on standard contract provisions, prescribing and onward referrals. GP Practices can also find helpful NHS standard template letters and other locally devised template letters by Cambs LMC
NHSEI Primary/Secondary Care Interface Guidance
National Health Service Standard Contract Template Letters
Cambs LMC Inappropriate Workload Template Letters
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:
- 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.
- 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.
- 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.
- 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.
It is important that patients expectations of an onward referral or testing, are not unduly raised.
“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 it has been recommended that a patient sees their GP about a particular issue, the patient should be asked to book an appointment with their GP, rather than this being put to the GP via a letter from the hospital. This avoids the patient falling through the net and saves a significant amount of admin time.
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.
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.
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.
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).
Prescribing guidelines and policies can be found here: https://www.cambridgeshireandpeterboroughccg.nhs.uk/health-professionals/prescribing-information/formulary-guidelines-including-shared-care-and-policies/prescribing-guidelines-and-policies/
For any prescribing queries, contact the CCG Medicines Optimisation Team email@example.com
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 Cambridgeshire & Peterborough Formulary can be found here: http://www.cambridgeshireandpeterboroughformulary.nhs.uk.
GPs will often decline to prescribe medicines listed in their local formulary where it is not recommended for prescribing in Primary Care, 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.
Some medications are subject to shared care. 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 shared care.
Local Shared Care Guidelines can be found here:
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.
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.
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 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;
- 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.
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.
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