Saul Miller is a GP in Wooler, Northumberland.
When I first heard it proposed, it made complete sense.
Tired of scanning hospital letters to try and spot if there was anything that would necessitate action, it seemed like a simple solution: hospital teams would in future put any such information into a headed section of each letter labelled ‘Actions for GP’. Nice and simple. No more hunting to spot the hidden homework. What could be easier than that?
And at first, that is pretty much how it was. But I should have paid more attention to that word ‘none’. It implied a mandatory text box, an asterisk that prevents one from moving on without saying anything.
I foresaw the days ending of the consultant letter dumping work on GPs as though we are merely remotely operating resident doctors.
It similarly struck me as a good news story when I first heard of plans to ensure all foundation doctors have at least one four month post in General Practice by 2030/31.1 I foresaw the days ending of the consultant letter dumping work on GPs as though we are merely remotely operating resident doctors. Consultants who have all experienced being on the other end of that equation will tread more respectfully and thoughtfully, I imagined.
It is correct to be suspicious of any government goal that commits a future government to the outcome but without generating a concrete blueprint for how to get there within its own term. But I naively overlooked that aspect of the NHS Long Term Workforce Plan.
Meantime, ‘Actions for GP’ has metamorphosed since it was introduced. The lure of the mandatory text box has proved too much. Templates now allow a department to pre-populate such letters, meaning the busy clinic clinician does not have to think too hard about the content because there is some trite advice already pre-written.
‘Please continue to manage the patient’s cardiovascular risk factors including blood pressure control, weight, cholesterol…’ might come from the cardiology clinic. ‘Don’t be an idiot and prescribe trimethoprim to this patient on methotrexate,’ might be the thoughtful reminder from rheumatology. Only psychiatry don’t join in the fun, probably mainly because the inevitable outcome of most assessments seems to be ‘…not our case anyway’.
Our Integrated Care Board (ICB) has a system of seeking input on some proposed policies prior to implementation. One such currently is a policy around the discharge of patients on long term antipsychotics for primary care follow up.
From a primary care perspective, I feel it is contentious for patients who are felt to be sufficiently severely mentally unwell to need high doses of antipsychotic medication, albeit chronically, to be discharged from mental health services. I feel more confident managing methotrexate than I do high dose quetiapine and yet patients on the former medication must remain with their secondary care initiator whereas the latter can be blithely handed off.
I feel more confident managing methotrexate than I do high dose quetiapine and yet patients on the former medication must remain with their secondary care initiator whereas the latter can be blithely handed off.
I have commented on this consultation, including to highlight that I view it as a good example of the structural inequalities between physical and mental health services. But when did you last experience a consultation in which the implementation plan didn’t simply proceed as planned anyway? For me, not for years.
But psychiatry letters are a case in point – they rarely come from doctors any more. Never mind the question about what proportion of NHS doctors are exposed to Foundation Training in primary care, it seems to matter little how well our consultant colleagues understand our milieu if the future of correspondence to GPs is for it to be delegated to others.
Next stop in this regression will be for artificial intelligence (AI) to take over clinic letter production, saving nurse specialists’ time too. I can’t begin to imagine what our AI overlords will want from primary care.
How interesting it will be to see where ‘Actions for GP’ ends up.
References
- https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/ (published 30.6.23, accessed 17.11.25)
Featured Photo by Sebastian Schuster on Unsplash
