A presentation for NHS staff on the key requirements in the NHS Standard Contract for England on working with general practices.

1. Improving how secondary care
and general practice work
together: the NHS Standard
Contract
Dr Amy Price & Professor Azeem Majeed
Department of Primary Care & Public Health
Imperial College London
Version 2.1
Copyright Imperial College London. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

2. Introduction
• Background
• What is the NHS Standard Contract?
• Limitations
• Take home points

3. Background: Increasing GP workload

4. • Current Crisis in general practice.
• The number of GP consultations in England rose from 303 million in 2008/09
to 361 million in 2013/14, an increase of 19%
• Case complexity has risen, with the number of patients in England with multi-
morbidities set to grow from 1.9m in 2008 to 2.9m in 2018.
• Between 2009 and 2014, the number of UK GPs (headcount) grew by just
0.2% (1)
• BMA survey of GPs in England:
• 57% felt their workload was excessive and that this impacted on the quality
and safety of care (2)

5. • Primary Care Foundation Report:
• processing information from hospitals was the second most burdensome
source of bureaucracy encountered by GPs
• demand created by hospitals was responsible for 4.5% of potentially
avoidable GP appointments
• problems with booking outpatient appointments (i.e. administrative errors or
missed appointments resulting in the need for repeat referrals), accounting
for 2.5% of avoidable consultations (3).

7. Impact on Patient Care
• Excess GP workload makes if difficult for patient’s to access primary
care:
• “you can be on the phone for hours trying to ring a doctor and you don't get anywhere.
So I ring now for the paramedics.” (5)
• Poor communication between hospitals and primary care can effect
patient safety:
• Studies show that delays in receiving, and often poorly written, discharge
summaries are a cause of prescribing and drug monitoring errors (6).

8. What has been done to address these problems?
• The General Practice Forward View (April 2016) set out a number of
pledges to prevent hospitals passing on unnecessary and
inappropriate work to primary care (7).
• It focused on:
• preventing patients from being sent back to their GP for a re-referral if they
failed to attend an outpatient appointment
• being sent back to their GP from secondary care for an onward referral for a
problem related to the original referral
• failure of secondary care to provide GPs with adequate information about
inpatient treatment; investigations; and medications

9. NHS Standard Contract
• Clear national requirements in the NHS standard contract for England
that secondary care providers must follow to prevent unnecessary
workload for GPs.
• Initially implemented in April 2016
• Updated in 2017 to include 6 further requirements (8)

10. NHS STANDARD CONTRACT 2017/18 and 2018/19 GENERAL CONDITIONS (Full Length)
NHS Standard Contract 2017/18
and 2018/19
General Conditions (full length)

11. Summary of Key Messages for hospital doctors
1. Onward referrals of patients
• There is no need for secondary care providers to refer back to the GP if the
onward referral is related to the condition for which the patient was originally
referred or the patient requires urgent investigation or treatment.

12. • 2. Did not attend (DNAs) and re-referrals
• Patients who fail to attend outpatient appointments cannot be automatically
discharged from outpatient clinics.
• Decisions about discharge from services can only be based on clinical
circumstances.
• 3. Managing patient care and investigations
• Secondary care providers must arrange, carry out and follow up all
investigations which relate to the original secondary care referral or
admission.
• They should not request GPs to carry out these tasks on their behalf.

13. • 4. Communicating with patients
• Secondary care providers must communicate the results of investigations
requested by themselves directly to patients.
• They must also make time to respond to any patient queries relating to the
care they have received in hospital.
• 5. Discharge summaries and clinic letters
• Discharge summaries must be sent to the GP within 24 hours for any inpatient
admission or A&E attendance.
• A clinic letter must be sent, within 10 days, after any attendance where the
GP is required to act in relation to the patient’s care.

14. • 6. Medication
• On discharge from an inpatient admission hospitals must provide patients
with a minimum of 7 days supply of medication.
• If patients require urgent medications following a clinic attendance the
secondary care provider must provide sufficient medication to last up until
the point when the GP can reasonably have expected to receive the clinic
letter relating to that attendance so they can prescribe appropriately.
• 7. Fit notes
• Secondary care providers must issue fit notes to their patients when
appropriate and for an adequate length of time, instead of expecting GPs to
issue these on their behalf (9)

15. How Is the Contract Enforced? (10)

16. Limitations
• Lack of knowledge amongst some GPs & hospital doctors
• Lack of positive incentives or sanctions for hospitals
• It is left to GPs to raise potential breaches of contract with hospitals
• Many CCGs seem uninterested in enforcing the terms of the contract

17. Take Home Points For Junior Doctors
• If a patient requires an onward referral for an issue related to their
admission, or if they require urgent treatment or investigation this
needs to be done as part of their hospital care.
• You must follow up the results of all investigations requested whilst a
patient is a hospital inpatient or requested in outpatient departments
and in Accident & Emergency
• These results should be communicated to the patient by a member of
the requesting team.
• Make sure that any queries that the patient has about their care in
hospital have been answered by a member of the team looking after
them.

18. • Make sure to check if your patient needs a fit note on discharge. This
must be issued for an adequate amount of time.
• Discharge summaries must be sent to the GP within 24 hours
• On discharge you must provide patients with a minimum of 7 days
supply of medication
• These requirements apply to hospital Accident & Emergency
departments as well as inpatient and outpatient units

19. GPs should not be asked to carry out any of these
tasks. The responsibility lies with the team
responsible the patient’s hospital care.

20. References
1. Royal College of General Practitioners. Patient safety implications of general practice workload. London: Royal College of General
Practitioners. 2015.
2. ICM on behalf of British Medical Association. Survey of GPs working in England. BMA.org.uk: Report number: 214685, 2016.
3. Clay H, Stern R. Making Time in General Practice. primarycarefoundation.co.uk: Primary Care Foundation; NHS Alliance. 2015.
4. Pulse. Reaction: DH crackdown on unnecessary workload dump on practices. 29 October. Available from:
http://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/referrals/reaction-dh-crackdown-on-unnecessary-workload-
dump-on-practices/20030326.article
5. Beech R, Henderson C, Ashby S, Dickinson A, Sheaff R, Windle K, Wistow G, Knapp M. Does integrated governance lead to integrated
patient care? Findings from the innovation forum. Health & social care in the community. 2013 Nov 1;21(6):598-605.
6. Slight SP, Howard R, Ghaleb M, Barber N, Franklin BD, Avery AJ. The causes of prescribing errors in English general practices: a
qualitative study. The British journal of general practice : the journal of the Royal College of General Practitioners. 2013;63(615): e713-
20.
7. England N. General practice forward view. 2016.
8. NHS England. NHS Standard Contract 2016/17 General Conditions (full length). england.nhs.uk: NHS England. 2016.
9. NHS England. The interface between primary and secondary care - key messages for NHS clinicians and managers. bma.org.uk: NHS
England. 2017.
10. (15) General Practitioners Committee. NHS England standard hospital contract guidance 2017-19. Available from:
https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-current-issues/nhs-england-standard-
hospital-contract-guidance-2017-2019.
Copyright Imperial College London. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.