Exclusive: GPs told to reduce hospital referrals as winter pressure hits NHS

GPs have been ordered to reduce hospital referrals and patients have been diverted back to practices from A&E as winter pressures start to drive up primary care workload.

GP referrals restricted (Photo: JH Lancy)

GPs in parts of London have been told to limit referrals or avoid referring patients altogether to some hospitals or specific hospital departments, as NHS England flags up 'capacity alerts' on the electronic referral service (e-RS) booking system.

One south London hospital has been calling local GP practices to secure appointments for patients waiting in A&E. GP leaders have also warned that patients are being discharged too early, driving up demand for home visits by GPs and in some cases having to be readmitted to hospital.

GPs have also warned that hospitals are piling extra pressure on primary care by failing to stick to requirements in their contracts for providing outpatient letters within 14 days and discharge summaries within 24 hours.

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GPonline reported last week on fears that restrictions on GP referrals would soar because hospitals were facing extreme pressure at the start of winter, with 94.5% of acute and general beds occupied in the week to 3 December. Data on hospital 'black alerts' are not being made public this winter - but evidence is growing to suggest that many will be unable to maintain comprehensive services.

Two thirds of GPs say their practice will struggle to cope this winter, and 90% expect the NHS as a whole to struggle - with GPs warning that patients will be put at risk.

Londonwide LMCs chief executive Dr Michelle Drage told GPonline that restrictions on GP referrals reflected an NHS in crisis. 'These attempts to compensate for a lack of capacity in hospitals are themselves symptoms of the overall problem facing the NHS,' she said.

GP workload

'Pushing work from hospitals into general practice only compounds the problem by taking up GP and practice nurse time that should be spent keeping people healthy in the community and out of secondary care. It also places even greater pressure on practices struggling with workforce shortages, increased demand and winter pressures.'

Following chancellor Philip Hammond's budget announcement of a £335m fund to ease NHS winter pressures, Dr Drage added: 'Seasonal gifts of cash to trusts are no substitute for sustained investment in general practice, community services and hospitals, which is required to create a system which properly supports its workers and patients.'

London GPs say that NHS England 'has placed capacity alerts on e-RS asking GPs not to refer to certain specialities at St George’s Hospital', while the hospital has called practices asking for appointments to be given to patients waiting in A&E.

Lambeth CCG is understood to have written to practices urging them not to refer patients to King's College Hospital, with a particular emphasis on A&E on certain days.

Winter pressure

GPs say that where hospitals fail to provide discharge summaries and outpatient letters promptly, practices face additional work because they are left to provide care for patients without vital information.

GP leaders have also warned that it is now 'routine' for GPs to be called out for home visits to patients a day after discharge from hospital. GPC member and Derbyshire GP Dr Peter Holden said earlier this month that through winter, numbers of patients sent home from hospital too early or without proper preparation increases - leaving GP practices to pick up the pieces.

A spokeswoman for NHS England (London) said: 'The pressures we face in winter are not unique to London but are faced by hospitals, GPs and health and care staff across the country every year.

'Regionally we are providing co-ordinated support to London’s health systems. Plans are in place across hospitals, community and social care services to manage increased winter pressures, including the expected increased instances of stroke, heart attacks and respiratory illness after a cold snap.

'In addition, we have issued clear messages to the public about self-care and using pharmacies and 111 as well as announcing that there are 75,000 extra GP appointments available for Londoners in the evenings and at weekends.'

A St George's Hospital spokesman said: 'Like all hospitals, there is significant demand on our services at present, particularly in our emergency department at St George’s Hospital (Tooting).

'We have escalation protocols in place to help us manage demand, and our staff are working extremely hard to ensure patients get the care and treatment they need.

'We continue to work with our colleagues in primary care, including local GPs, to ensure only the most appropriate patients are seen within our emergency department.'

Explaining why details of hospital 'black alerts' - officially known as alerts under the operational pressures escalation levels (OPEL) framework - were not being made public this winter, an NHS England spokesperson said a 'better system' was in place this year.

'The NHS nationally has introduced a better system this year for identifying, and acting upon, heightened operation pressures over winter. This is centred around the new national emergency pressures panel, chaired by the NHS' medical director Sir Bruce Keogh, and its decisions about raising, or reducing, their assessments of pressure will be made transparently and published.'

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