• Cease non-contractual activities that are voluntary and/or completely unfunded. These services are non-contractual, and are often undertaken by GPs to plug local service gaps, but they would be more appropriately and safely provided within secondary care services.   
• Professional obligations may require consideration of serving appropriate notice on ceasing such services, for example, where a practice has been providing such services for a significant period of time, despite not being resourced to do so.   

Activity falling under these actions include:

• Undertaking ECGs where this is more appropriately delivered in secondary care  
• Preprocedural medications or medications used for hospital tests (as per HSS MD 26/2022)  
• Complex wound and ulcer dressings/post-op wound care where there is no enhanced service with the appropriate governance requirements in place  
• PSA / MGUS chronic monitoring   
• Bloods for secondary care, particularly those with clinical risk (e.g. PSA with unusual reference interval)   
• Urgent scripts for secondary care services such as Psych Home Treatment teams (unless funded to do so)  
• Non-emergency ambulance ordering e.g. for first outpatient attendance   
• New activity associated with waiting list initiative  suggesting GP provision of pre-/post-op care  
• Fit Notes through Epic for patients under their care of Trust at outpatient or on discharge from acute care.  

This is a non-exhaustive list intended to give individual GPs, their practices and Local Medical Committees an idea of what this action intends to incorporate. Local circumstances will need to be considered and action taken as appropriate.   

Why are we taking this action? 

• This action highlights the work that many GPs currently undertake but for which general practice is not funded. Such activity can make existing contractual obligations harder to deliver, impacting upon patient access and potentially risking service quality, safety, and staff illness/burnout.   
• Many of these actions are already in line with the existing Working Better Together consensus document, however, are not currently adhered to consistently.  

How will we take this action?  

• Using template letters as appropriate 
• Communicating with patients and signposting them to alternative services as appropriate.  

Template letters for download

• General transfer of work response
• Secondary care prescribing request response
• Response to requests for post-operative checks
• Response to requests for post-operative checks
• Response to requests to follow up investigations performed in other settings

• GPs make clinical decisions on whether to make referrals for specialist secondary care, based on their best judgement and professional obligations. Using the Clinical Communication Gateway (CCG), GPs have distinct options - either to refer for a face-to-face appointment with an appropriate specialist or, for a limited number of specialties, request advice and guidance from a specialist on how a patient’s treatment can be locally managed.    
• In some instances, HSC Trusts unilaterally change a GP referral for a face-to-face appointment to a request for advice and guidance, effectively discharging the patient with advice on local management. GPs are often left to facilitate and communicate this to the patient, despite it conflicting with their clinical decision that referral for face-to-face secondary care is advisable.   
• Unless the guidance on local management is either specifically requested, or is otherwise timely and clinically helpful, GPs should write back to the HSC Trust, re-referring the patient and insisting on appropriate specialist provision. When writing back, the GP should insist that the Trust communicate directly with the patient, rather than via the GP.   

Why are we taking this action? 

• To prioritise what is in the patient’s best interest clinically by ensuring as far as possible that specialist secondary care is provided when required.  
• To reduce unnecessary and unfair administrative burden being placed on GPs by secondary care providers. Whilst there may be instances where advice and guidance response work for GPs and their patients, when provided unilaterally and not in consultation with the GP, it can lead to lengthy back and forth discussions, taking time away from direct patient care.   
• GPs also have a professional duty to raise concerns if overassertive triage is creating a potential safety issue around blocking access to secondary care.  

This action is in line with the Working Better Together consensus document, including the following guidance:  

• Secondary care clinicians should not refer back to general practice unless necessary.  
• Secondary care colleagues should be responsible for onward referral without referring back to the GP if the problem relates to the original referral.  

How will we take this action?  

• Template communication, via CCG or as appropriate: Insist on referrals for specialist appointments when clinically appropriate
• Ensure patients are informed of actions being taken in their interests.   

• GPs currently complete large volumes of paperwork which is not required by their contracts but plugs gaps in the wider health and care system. Often this is unfunded and has no direct link to patient outcomes. Where this is the case, requests to complete paperwork may be redirected to the other appropriate agencies.  
• There is an assumption that in order to access other statutory services a letter or note from a GP is required. However, this is rarely the case and furthermore is it not resourced. Certain GP paperwork can be required to ensure patients can access other statutory services, however this is not resourced.   

One significant example could be paperwork associated with patient registration - GPs and practice staff may cease taking actions to gather and verify documentary evidence to assess entitlement to NHS healthcare. This instead should be forwarded to the BSO for entitlement to be determined. Other high-volume examples may include un-resourced drafting of letters: 

• to support patient applications for social housing  
• to support educational provision in schools   
• to support applications to the Home Office   
• to support reports for benefits applications.  

 This is a non-exhaustive list intended to give individual GPs, their practices and Local Medical Committees an idea of what this action intends to incorporate. Local circumstances will need to be considered and action taken as appropriate.   

Why are we taking this action? 

• This action highlights the work that many GPs currently undertake but for which there is no additional resource. Such activity can make existing contractual obligations harder to deliver, potentially risking service quality, safety, and staff illness/burnout.  
• This action is broadly associated with the corresponding action to serve notice on any activity that is considered to be voluntary and completely unfunded. GPs have reported a specific burden on practices associated with over-bureaucratic, non-essential paperwork.   

How will we take this action?  

• With regards to verification of patient documentation to ensure eligibility for NHS services, GPs can continue to see and treat patients whilst eligibility is determined, however, BSO will need to chase up what, if any, additional documentation a patient is required to provide to enable it to make a determination on eligibility. Current provision allows for capitation to be paid quarterly, until an entitlement to NHS care is rejected by the BSO  
• GPs, their practices and Local Medical Committees can determine individual and collective approaches to the other types of paperwork they will cease to complete and how this will be communicated to patients and other agencies.