Piloting patients through the straits of NHS administration

Authors: Michael Ingram 

Publication date:  08 Apr 2013

Precious GP time is being swallowed up in protecting patients from the increasing administrative failings of the NHS, says Michael Ingram

The skill set of a peripatetic, community, hospital appointments clerk does not appear anywhere in the general practitioner (GP) vocational training scheme manuals. Yet the ability to secure appropriate care for your patients is one of the most time consuming and, in terms of patient safety, most essential skills that the new entrant to the profession requires.

For instance, take a phone call I recently received at the end of a long day. “Sorry to give you more work,” apologised the daughter of an elderly patient of mine. “I keep ringing the secretaries and they say they cannot give me the result of mum’s gastroscopy. They say I have to ring her GP.”

I looked, and there was a report on screen, one month old, suggesting some atypia and the possibility of a gastric lymphoma. It ended “histology awaited,” with no other clue given. Needless to say, I had no histology results and nothing to tell the patient or the next of kin. This led to a tricky, frustrating, and delicate situation, with the GP, as ever, left carrying the can.

One anxious daughter spending time repeatedly ringing the hospital, one hospital doggedly refusing to communicate the results of the test that they had carried out, one GP dealing with an issue that should never have arisen, and a few hours of staff time ultimately led to the results being faxed through. But all of this drains general practice’s already diminishing energy reserves.

GPs reading this will barely raise an eyebrow. They will recognise the simple fact that the increasingly complex and onerous workload of general practice has been exacerbated by the failings and petty policies of most hospital trusts. As a result, an enormous amount of precious GP time is swallowed up in protecting patients from the increasing administrative failings of the NHS. It has been estimated that a third of GPs’ workload entails dealing with issues and problems from their local trust.

Not a day goes by without a letter needing to be written to request a new appointment for patients who have failed to attend outpatients because, for example, they were inpatients in the same hospital or they never received notification of their appointment. There is also the subtle variation where a patient is promised a follow-up appointment but notification of it never arrives. The promise “an appointment will follow in the post” seems to be as reliable as “the cheque is in the post.”

As if this is not punishing enough, there is the added complication of the Einsteinian time frame for follow-up appointments. “I will review the patient in 6 weeks” in a clinic letter is translated into an appointment four months later, and GPs are left fighting for an earlier review.

Sometimes this goes a step further. A colleague recently received a discharge summary starkly, and dangerously, stating “GP to chase histology” after a procedure, as if dropping a few words into a computer would summon a servile dogsbody to carry out their whim. It is not meant in an arrogant way, though it comes over as nothing less. It is a product of industrialised hospital care that is obsessed with waiting list targets and processing patients, leaving others to tidy up the loose ends.

In other trusts, the churning of patients to generate referrals and thus revenue means that patients are sent back to their GP for another referral as the hip surgeon cannot deal with ankles. Even worse, many GPs in London have their valuable appointment slots filled by patients attending after their outpatient consultation to collect a prescription for a drug that the hospital will neither initiate nor prescribe because to do so would incur cost in both provision of the drug and in staffing a pharmacy department. The stock order is, “Go and see your GP in a couple of days.”

Our consultant colleagues are clearly being battered. The impression I get is that they are overwhelmed and focused on working hard in their particular area of medicine and trying to offer the best care. At the same time, the administration and management of hospitals institute complexity and inflexibility as they try to meet both financial and performance targets from above.

Twenty three years ago, the Thatcher government introduced the purchaser-provider split. That started the dissolution of a unified approach to patient care that is needed more than ever, given the demographic expansion of complex chronic need.

As the last holistic generalists are switched from providing medical care to piloting patients through the treacherous straits of non-existent appointments and unreported results, this split care model is looking more and more like a wrecked and sinking behemoth.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Patient consent obtained.

Michael Ingram GP partner The Red House Surgery, Radlett, Hertfordshire, UK


Cite this as BMJ Careers ; doi: