Workload transfer in the NHS: The Great British Dump

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on X: @nadafkhan

t’s late on a Tuesday evening, and you are piling through letters after a busy clinic. You come across a discharge summary for a patient who has had a short one-day admission to hospital with abdominal pain and collapse. As you read the ‘Actions for GP to complete’ section, you read, ‘GP to refer onwards to gastroenterology, arrange 24 hour ECG, follow up outstanding blood results including coeliac screen, and repeat U&Es in one week. And please issue a fit note as needed’. Your blood begins to boil. This is the great British dump.

Dumping, or by a more polite way of describing it, the inappropriate delegation of work, is not new, but in recent years GPs have described an increased shift in the tasks from secondary to primary care without an associated increase in resources.  Increasingly complex patients are discharged from secondary care follow up earlier, which leads to more tasks, more appointments and more work in a general practice already under pressure.¹

The touchpoints for workload dumps

The common touchpoints for transferring tasks between primary and secondary care are when patients move from general practice to specialist care and back again, either through an admission to hospital or after a hospital outpatient appointment.

After spending time in hospital, a good hospital discharge summary ideally acts as an important handover document about what happened, summarising changes to diagnoses and medication.  Discharge summaries are important documents that can provide crucial information about patient care, and when information and tasks are handed over effectively, these summaries can reduce harm to patients.  But what happens when tasks are inappropriately delegated back to general practice? One retrospective analysis of tasks from hospital discharge summaries deemed 33% of tasks delegated to GPs as inappropriate as they were part of the hospital-initiated tests and investigations that should have been followed up by the hospital team.²  Similarly, GPs speaking to the Parliamentary Health and Social Care select committee highlighted long lists of tasks requested by hospital specialists, including requests for blood tests or medication changes, which add to the general practice administrative burden.³

GPs can feel understandably frustrated by inappropriate delegation of workload such as referrals and tests on hospital discharge and outpatient letters, but most ‘reluctantly’ accept these tasks as part of their work.⁴  Other GPs are more active in pushing back at work dumped on them, and the BMA has published letter templates for practices to integrate into their clinical systems for just this purpose to quickly push back on inappropriate workload.  The letter templates include responses to inappropriate workload transfer and prescribing requests (including medications that need initiation and titration in secondary care), requests to follow up secondary care investigations, and asking for re-referrals for patients after a missed appointment in hospital.  Pushing back is one way of taking a stand, but GPs acknowledge that this often takes more time than just completing the task asked of them, though it might possibly prevent getting asked to complete similarly inappropriate tasks in the future.⁴

But it’s not just discharge summaries and outpatient letters.  With waiting lists increasing in secondary care, it increasingly feels that there is push back on referrals, especially with a recent call to introduce an advice and guidance first approach to all referrals.  When used well, advice and guidance feels more akin to a collaborative approach to working with secondary care colleagues, and is a communication pathway to getting quick advice about how to manage patients, with specialists converting the request to a referral if it’s appropriate.  The outpatients lead for the Royal College of Physicians, however, pitches advice and guidance in a slightly different light, suggesting it could be used to ‘maximise pre-referral interactions’ to deliver more care closer to patients’ homes.⁵  Specialists feel that GPs can save time and shorten waiting lists for them by solving more problems in the community.⁶  Does this sound like dumping, or a barrier to sending referrals, or a sensible approach to make the referral process smoother and reduce waiting lists?  GPs and consultants have previously warned against a ‘ping-pong’ style of communication across the primary and secondary care interface where each side tries to set boundaries on their responsibilities. Ultimately, this approach can just lead to clinicians feeling more frustrated and siloed.⁷  Like many issues crossing the primary and secondary care interface, your opinion on this is probably a matter of perspective.

The flipside of the great British dump

Now, imagine that you are a medical registrar working in a busy acute medical unit at 2am on a Tuesday evening.  You go to clerk a patient who has been sent into hospital by a local GP with abdominal pain and a recent collapse.  There is no clinical information with the patient, who is confused and alone, but the ambulance handover includes a scribbled note from a GP that reads, ‘can you please see and treat this patient?’.  Your blood begins to boil.

This is the flipside of the great British dump.  Specialists share that sense of injustice about abdicated responsibility when they feel that patients have been inappropriately referred to them, or when patients are referred in areas of care previously covered by GPs, for example, out of hours care, or management of conditions such as childhood constipation.⁷  Some of this might feel obvious, but the RCGP Primary-secondary care interface guidance includes primary care standards, including making sure that any appropriate primary care pre-referral tests and assessments have been completed and making clear, for our specialist colleagues, why a patient is being referred to them for care.⁸

Colleague professional behaviour and collaborative practice

GPs and specialists value their professional autonomy, so when work is being inappropriately passed their way it can impact on those professional feelings and boundaries.  In a Scottish study, GPs and consultants talked about the inappropriate transfer of work in terms of problematic professional conduct.  GPs felt that specialists were not accepting their professional responsibility when they inappropriately delegate work. However, this sentiment was mirrored by specialists.⁷  And when tasks were resisted, this really impacted on a sense of goodwill and ‘being in it together’ for the patient.  This brings us back to focussing on what’s really at stake, because at the end of every dumped task is a patient needing care.  Perceived dumping can lead to tasks not being completed, and these failures to act on test results, complete follow up and engage with external referrals impact on patient safety.

So, is better collaboration the key to reducing these feelings of frustration and disappointment?  One way to facilitate collaboration is to encourage doctors to meet each other and to better understand each other’s working method.  Establishing personal relationships is fundamental for the development of improved communication, trust, and collaboration, and is a way for specialists and GPs to increase their professional knowledge.⁹ And when collaborative practice works well, it’s a way for colleagues across primary and secondary care to use those trusting and respectful relationships to put patient care at the heart of their work. Facilitators to developing better transfer of work across the primary and secondary care interface include getting doctors in the same room to develop those relationships, perhaps through shared educational events or by spending more time in each other’s workplaces either during training or during formal professional exchanges.⁷  The BMA and the RCGP have both suggested that all health care professionals working in hospital should spend a year or more working in general practice in an attempt to reduce the cultural chasm between hospital and general practice perceptions about whose work is whose.

Where do we go from here?  Inappropriate transfer of workload can go both ways, and it can feel highly frustrating for GPs and hospital specialists alike.  But as patient care becomes increasingly fragmented, thinking locally about how to improve collaborative care might help build back those relationships across the primary and secondary care interface, and make those professional interactions safer for patients.

References

1. Croxson CH, Ashdown HF, Hobbs FR. GPs’ perceptions of workload in England: a qualitative interview study. Br J Gen Pract. 2017;67(655):e138-e47.
2. Mughal Z, Maharjan R. Cross-sectional analysis of hospital tasks handed over to general practitioners: workload delegation or dumping? Postgrad Med J. 2022;98(1161):e14.
3. The future of general practice: Fourth report of session 2022-23. House of Commons, Health and Social Care Committee; 2022.Contract No.: HC 113.
4. Spencer RA, Rodgers S, Salema N, Campbell SM, Avery AJ. Processing discharge summaries in general practice: a qualitative interview study with GPs and practice managers. BJGP Open. 2019;3(1):bjgpopen18X101625.
5. Iacobucci G. Restricting direct GP referrals must not be a barrier to care, says RCGP. BMJ. 2023;382:2187.
6. Berendsen AJ, Benneker WH, Schuling J, Rijkers-Koorn N, Slaets JP, Meyboom-de Jong B. Collaboration with general practitioners: preferences of medical specialists–a qualitative study. BMC Health Serv Res. 2006;6:155.
7. Sampson R, Barbour R, Wilson P. The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study. BMC Fam Pract. 2016;17:45.
8. Primary-Secondary Care Interface Guidance: Royal College of General Practitioners; 2023, Available from: https://www.rcgp.org.uk/getmedia/dbbcac28-b1c9-455a-b2b8-d6f0cd815258/Primary-secondary-care-interface-guidance.pdf.
9. Berendsen AJ, Benneker WH, Meyboom-de Jong B, Klazinga NS, Schuling J. Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study. BMC Health Serv Res. 2007;7:4.

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