We are able to provide phlebotomy and other procedures on behalf of secondary care in the following circumstances:

• Where there is an existing Locally Commissioned Service (LCS), which we have signed up to (e.g. warfarin monitoring, PSA monitoring).
• Blood tests prior to outpatient attendance (under the Procedures requested by secondary care LCS). This is for one-off requests before an out-patient appointment or chemotherapy – but only if the patient comes with a fully completed blood card from the clinician requesting the test, with that clinician’s contact details clearly provided, to ensure the results go directly to them. If the blood card and contact details are not provided, we will not be able to do the test.
• Near patient testing as part of shared care drug monitoring.
• Aural toilet only ahead of an ENT appointment under the LCS.
• Where otherwise necessary to support a referral, eg C&E before colonoscopy, ECG for a cardiology referral.

For the avoidance of doubt

• We do not provide a regular phlebotomy or physical monitoring service for secondary care, CAMHS, AMHT or eating disorder service, other than as part of an existing LCS shared care arrangement, which has been explicitly agreed to, by us, in advance.
• As a reminder, practices are not obliged to take on monitoring under the near patient testing LCS and are free to decline if they don’t feel it is appropriate. As a practice we have elected not to take over responsibility for monitoring ADHD medication in newly diagnosed children, as we feel they should remain under specialist supervision.
• We will of course continue to do blood tests and appropriate monitoring of coexisting conditions normally managed entirely in primary care. However, we expect monitoring for conditions that should be managed by secondary care (including the physical monitoring, blood tests and ECGs of patients with anorexia) to be carried out by secondary care, as we do not have the resources, experience or expertise. Patients who are on our QOF mental health register receive an annual health check to include BMI, BP and bloods as part of the GMS contract.
• We are not able to provide ECGs on behalf of secondary care, CAMHS or the AMHT.
• We will no longer provide weight or BMI monitoring on behalf on CAMHS or AMHT.
• We are not able to provide BP monitoring on behalf of secondary care, CAMHS or AMHT.

Background to updated guidance

We have had to update our policy on providing investigations and monitoring (and follow up of these) on behalf of secondary care.

In the past we have been happy to support secondary care by doing occasional blood tests and other investigations. Much of this has been done as part of an agreed shared care arrangement.

More recently we have had a huge surge in demand from patients attending for tests that secondary care has told them to have done by primary care, but in the absence of any agreed arrangement. The reasons for this are multifactorial. They include a shift towards telephone consulting by secondary care and a steady flow of unfunded work from secondary to primary care. It is also because of a lack of resources and capacity in other parts of the system.

This un-resourced demand is reducing availability of appointments for our own blood tests, ECGs etc. There are sometimes unrealistic expectations of when these tests must be done, and often they can’t be done in the expected timeframe without disrupting other clinics as fit-ins.

Patients are frequently coming without blood forms (creating delays in clinics whilst phlebotomists need to interrupt GPs to work out what may be needed and generate forms).

Results are being returned to us rather than the requesting clinician. This causes problems when dealing with abnormal results, particularly as it is so difficult to contact the appropriate secondary care clinician and ensure they are taking responsibility for tests they requested. This creates additional work, often for a duty doctor who doesn’t know the patient, or the context of the tests requested and is potentially unsafe.

Most challenging, is the expectation for us to take on monitoring of patients due to lack of capacity or lack of appropriate resources in other systems that should be providing such care. This is happening either whilst patients are on waiting lists to be seen (without any responsibility from secondary care for the tests in the meantime), or even instead of accepting a referral at all. We do not accept this responsibility should fall on general practice by default, this is unsafe for patients. General Practice is also experiencing exceptional demand and is not resourced or specialised enough to safely do what should be done by secondary care.

These new guidelines are provided with the intention of facilitating the safe and effective care of our patients with the resources we have.