Irfan Malik, a GP in Sherwood, said he feared for patient safety – and was having to advise people to consider private healthcare because accessing services was becoming so difficult, reports the British Medical Association.
Dr Malik was talking to former Nottingham Post Health Correspondent Peter Blackburn, who now works for the BMA. Doctors have raised concerns that the situation is being driven by stretched NHS funding, limited workforce and the mounting backlog rather than in the pursuit of improved patient care.
Nottinghamshire GPs have raised concerns about patient safety and the emergence of a two-tier healthcare system after the introduction of a new virtual triage system, that has reduced the number of patients able to access specialist neurology services.
Dr Malik said: "‘Neurology is a difficult subject and it is hard to diagnose properly from our end in general practice.
"We get a wide range of patients, and we are not always qualified to make the diagnosis or carry out the specialist tests. We only refer when we absolutely have to, but more and more referrals are being rejected with advice and patients not seen."
He continued: "Every referral is becoming a battle and a struggle, they send a letter back with lots of advice and things to do and other referrals to make. The patients are getting stuck and they still have the problems they initially had."
Dr Malik explains the "frustrating" situation where in some of his clinics more than half of the patients are waiting to have something done in hospital and are "stuck" until then. He said: "What can we do? It feels like people will get more and more poorly and some will have bad consequences."
Data shows that the number of patients not being seen in secondary care in Nottinghamshire has risen, with a rejection of referrals or advice and guidance being issued for 40% of cases in 2022. This is a substantial rise from 7% in the 12 months prior to the pandemic.
Nottingham University Hospitals NHS Trust runs two of the biggest hospitals in the city and says it introduced the new system due to "greatly" increased referrals and a lack of staff. However, the trust's figures show the total number of referrals have been significantly higher than they are now.
The last six months of recorded data, from November 2021 to April 2022, show that on average there were 428 referrals a month, whereas in the six months leading up to March 2020 it was only 611.
Nottingham GP and BMA East Midlands co-vice chair, Kalindi Tumurugoti, explained that the problems were causing significant issues around workload too. He said: "Any referral that is rejected or returned generates a huge amount of work in general practice."
"It is a case of seeing what to do next, looking at further investigations, considering pain relief and medicine management and trying to access MRIs or other steps that may be required. We are already a stretched and demoralised workforce and this is effectively going to give patients second-class treatment."
NHS leaders in Nottingham says they introduced the virtual triage system for outpatient referrals in line with national guidance and co-designed with primary care partners in order to address challenges that arose from the pandemic in July 2020.
A briefing document from the NUH discusses the issues and says that a "conscious" decision had been made to "carefully vet all referrals from primary and secondary care." Michael Wright, chief executive of Nottinghamshire local medical committee, says local GPs had raised concerns over the increased use of advice and guidance is "effectively a way to control workload rather than address genuine clinical need."
Mr Wright said: "This also causes practices extra work and GPs would feel that they’ve discharged their contractual duties responsibly by referring the patient and would prefer to use advice and guidance when looking for pre-referral help as the name suggests, advice and guidance."
He explained that the LMC was aware of situations where patients were facing long waits and where GPs felt they needed to suggest they consider private treatment. Mr Wright said: "This may be the reality of the situation, some patients are also opting for private GP care."
As GPs have raised concerns that significantly increased use of advice and guidance could be normalised and be dictated to other NHS policy areas, but Mr Wright says local GPs should work "collaboratively with the trust to make the best of a difficult situation and try different approaches."
He continued: "‘We are working with the hospital trust to identify problems in the primary-secondary care interface and work on them together. We are very clear on where we feel the relationship is adding workload on to practices and want to be part of changing the situation.
"The whole notion of integrated care systems is around joining up the services to do the best for the population addressing health needs, this is a system issue and an early test for the Nottingham and Nottinghamshire [integrated care system]."
Local politicians have also raised concerns. The NUH told The Doctor that the new virtual triage service shows that "the majority of referrals were seen virtually or physically but a significant proportion were returned, often with either a request for additional information or a management plan."
The NUH added that 15% of patients were re-referred to the service after six to twelve months, and less than 10% of patients subsequently presented to hospitals run by the NUH with symptoms relating to their original referral symptoms.
NUH medical director Keith Girling said: "Our neurology service adopted a virtual triage system for outpatient referrals in line with national guidance. This was agreed and co-designed with local primary care partners and addressed challenges raised during the pandemic, catering especially for those in need of specialist care."
James Hopkinson, joint chair and clinical lead at Nottingham and Nottinghamshire clinical commissioning group, added: "We continue to work with all elective services in Nottingham University Hospitals and are trialling different approaches in consultation with colleagues in primary care including using technology for remote consultations and increased use of advice and guidance."