1. The contractor must take steps to ensure that a patient contacts the contractor:
(a) by attendance at the contractor’s practice premises
(b) by telephone
(c) through the practice’s online consultation tool or
(d) through a relevant electronic communication method.
2. The appropriate response is that the contractor must:
(a) invite the patient for an appointment, either to attend the contractor’s practice premises or to participate in a telephone or video consultation, at a time which is appropriate and reasonable having regard to all the circumstances, and the patient’s health would not thereby be jeopardised;
(b) provide appropriate advice or care to the patient by another method
(c) invite the patient to make use of, or direct the patient towards, appropriate services which are available to the patient, including services which the patient may access themselves, or
(d) communicate with the patient:
o to request further information
o to convey when and how the patient will receive further information on the services that may be provided to them, having regard to the urgency of their clinical needs and other relevant circumstances.
3. The appropriate response must be provided:
(a) if the contact under sub-paragraph (1) is made outside core hours during the following core hours.
(b) in any other case, during the day on which the core hours fall.
4. The appropriate response must take into account:
(a) the needs of the patient; and
(b) where appropriate, the preferences of the patient
Though the BMA may agree with the aspiration of this amended regulation, GPC England (GPCE) believes that this requirement is not achievable for many practices with current resources and workforce.
With GPs numbers decreasing, consultation numbers higher than ever, and general practice being under-resourced, the BMA think this government-imposed contract will push GPs and practices to the brink of their existence, within the NHS.
For this and other reasons GPCE rejected the contract changes. The government has made it clear that this contract, rejected by the profession, will come into force.
Practices where care navigation is used to allocate patients to appropriate services have various possible dispositions for patients who contact the practice, as set out in paragraph 2:
offer on-the-day assessment by another clinician for cases perceived to be urgent
offer assessment at another time by a clinician for cases relating to longer-term and non-urgent conditions
signpost to another service where another service is appropriate e.g. mental health support, community services, community pharmacy
signpost to 111, UTC, overflow hub when capacity in the practice is reached
Request further information – for example via digital tools available to surgeries.
Paragraph 2 does not stipulate the time frame in which a further assessment or appointment is to be offered, it says “at a time which is appropriate and reasonable having regard to all the circumstances”.
However, QOF and IIF targets aim to have patients seen within 14 days of contacting the practice. Some practices will be able to achieve this, but if practices cannot, this is not a breach of the contract.
Paragraph 3a places the requirement that practices respond to contacts “outside core hours” in core hours following the contact. However, practices can choose to turn off online consulting methods outside core hours which will enable more capacity to respond to in-hours (8am-6.30pm Mon to Fri) contacts.
GPCE sees the use of care navigation as a potential solution to this imposed contract stipulation, but practices may have other innovative ways of managing this issue such as total triage. The BMA do not advocate a move back to the duty doctor or other systems which place an unnecessary and unsafe burden on GPs.
How do these changes to regulations affect safe working guidance?
Practices that attempt to achieve the requirements may do so at the expense of clinician wellbeing and patient safety. GPCE safe working guidance recommends that clinicians have no more than 25 clinical contacts per day. Making more decisions than this can lead to decision fatigue, clinical errors and patient harm, and clinician burnout.
GPCE thus advises practices to protect patients and clinical staff from these risks by limiting clinical contacts to no more than 25 per day for each GP, and any excess demand beyond this being signposted to other settings such as 111, overflow hubs, or urgent treatment centres.
This is permitted within the contract which says that patients should be offered an assessment of need or be signposted to an appropriate service.
The new requirements do not enable practices to ask patients to call back another time, therefore, when safe clinical capacity is reached patients should be signposted to other settings as described above.
ICBs should ensure that there is a formal escalation route for practices that have reached safe capacity. Operational Pressures Escalation Level (OPEL) measurement should be used, and escalation plans should be agreed by practices, LMCs, and ICBs to enable safe onward signposting of patients. Until formal escalation plans are agreed in localities, practices should signpost patients to where they feel clinically appropriate.
Investment is required to recruit care navigators, develop care navigation systems, and provide premises and infrastructure to enable all practices to make the mandated assessment. The BMA recommend that practices write to their ICB requesting this investment to enable them to achieve these requirements safely.
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