Preserving the integrity of general practice

Time spent on secondary care requests is time taken from primary care patients

GPs are gatekeepers to secondary and tertiary care. We deal with medical, psychological, and social problems that do not need specialist input. We do this all day, every day, becoming expert at managing complex problems for the benefit of both patients and the healthcare system, making sure that only patients that cannot be managed by us find their way to secondary care. Put simply, we keep people out of hospitals and outpatient clinics so that those that need specialist care can access it.

But gatekeeping works both ways. Effective general practice means that we must also respectfully decline to take responsibility for care that belongs elsewhere. We must not allow our resources to be consumed by problems that should be treated, investigated, and followed up in secondary care. We must not see ourselves as a solution to the shortcomings of other institutions, organisations, or healthcare providers.

I am referring to the increasing number of requests from different sources for imaging, blood tests, swabs, referrals to other specialists because of incidental hospital findings that amount to the ever-increasing demands of what is now called ‘transitional care’, and the phrase that often accompanies these requests, ‘GP kindly follow-up’.

Dr Mark O’Kelly spoke about this problem on a recent Irish College of GPs (ICGP) webinar. He pointed out that poorly managed transitional care not only impacts the GP workload, it also significantly increases the risk of adverse patient outcomes, with convincing evidence to suggest that this transition from secondary/tertiary to primary care is one of the most vulnerable parts of a patient’s journey. Often such requests for follow-up or additional investigations are buried in the body of a lengthy discharge letter, accompanied by a list of unflagged medication changes that need immediate attention, and, frequently, the patient is unaware of the proposed plan. Such information can be missed by even the most discerning and conscientious among us as we wrestle with the tsunami of letters and results that flows into general practice daily.

Transferring responsibility for follow-up to GPs in this manner puts patients at risk of delayed care, missed care, and mismanaged care – if a referral is sent out of context – but, most of all, there is the missed opportunity for GPs and their patients, as when we spend time doing this additional work, we are not doing the work of general practice. Time spent on secondary care requests is time taken from primary care patients. Like secondary care, general practice has finite resources, and it is in our patients’ interest that we protect them and use our time and our expertise wisely and effectively.

Following the example of the British Medical Association and the Royal College of General Practitioners, the ICGP formed the transitional care working group to look at the extent of the ever-increasing transfer of workload to primary care and to help members respond to these demands. In doing so, they consulted the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2024), and developed useful templates that can empower GPs to push back respectfully and ethically against incomplete or poorly managed transitional care, and avoid taking on additional risk. Medical Council guidelines state that in the interests of patient safety, care should not be handed over without checking that the recipient (in this case the GP) fully understands and accepts responsibility for follow-up. It is not enough to send a list of desired instructions. Proper and complete communication is key. In another section, the guidelines state that it is the responsibility of the doctor who orders diagnostic tests or investigations to make sure that these tests are carried out, and follow up on the results to ensure that appropriate actions have taken place. This includes complete communication to the GP. This clearly suggests that the responsibility for follow-up rests with the initiating clinician to maintain patient safety. In other words, ‘do the test, do the rest’.

Direct GP access to imaging has improved patient care but if we start using this to make up for the shortcomings of secondary and tertiary care, we will soon be back to long waiting lists and a system that does not meet our patients’ needs. If every GP sends requests for hospital scans through the primary care system, there will be no true primary care access.

While it is important to collaborate with hospital colleagues, it is equally important to preserve the integrity of general practice. I would like to think that the general practice systems that we hand on to the next generation of GPs will be fit for purpose. That future GPs will work both autonomously and in close collaboration with hospital colleagues, in a system that nurtures mutual respect for the responsibilities and limitations of the resources of all specialties, and that keeps patient safety as a priority at all stages of care.