17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We also look at whether there are signs the events complained about had a negative effect which the organisation has not put right.
Failure to refer
18. To establish what should have happened with the pain team referral, our adviser referred us to the NHS England standard contract. It provides information about onward referral. It says ‘for a non-urgent condition directly related to the complaint or condition which caused the original referral, onward referral to and treatment by another professional within the same provider is permitted, without reference to the patient’s GP’.
19. Our adviser also referred us to the BMA guidance, primary and secondary care working together. It provides information about managing onward referrals. It says ‘clinicians working for the provider should make an onward outpatient referral, without needing to refer back to the GP, where it is directly related to the condition for which the original referral was made, or the patient has an immediate need for investigation or treatment’.
20. Our adviser also referred us to the RCGP, primary-secondary care interface guidance. It says secondary care standards clinicians should ‘arrange onward referral, without referring back to the GP, where appropriate and locally agreed’.
21. The neurosurgeon at UCLH requested the GP practice refer Mr B to the pain team for a related condition. The guidance tells us in these situations, the hospital clinician should send the referral, not the GP practice.
22. There seems to have been a dispute between the GP practice and the neurosurgeon about who should make the referral to the pain team. We understand this must have been frustrating for Mr B.
23. The request from the neurosurgeon to the GP practice was for a referral to the pain team service within UCLH. Therefore, the GP practice believed the referral to be within the same Trust. We have seen nothing in the records to indicate Mr B was out of boundaries for this referral to the pain team. The medical records show the neurosurgeon was based at a hospital within UCLH. We have seen nothing to indicate there were any alternative local agreements in place.
24. We can appreciate why Mr B was frustrated when he found out the GP practice had not made the referral. There is no indication the GP practice needed to make a referral to the pain team within UCLH and it acted in line with its NHS England standard contract, BMA guidance and RCGP guidance.
Delay in acting on the letter dated 2 June 2023
25. Mr B does not understand why the GP practice did not act on the letter from the neurosurgeon dated 2 June straightaway.
26. To establish what should have happened with this letter, our adviser referred us to GMC Good medical practice. It says to ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary’ and ‘be willing to explain your reasons for the options you offer (and the options you don’t) and any recommendations you make’.
27. The letter from the neurosurgeon dated 2 June says Mr B was keen to seek a pain team opinion and then asked the GP practice to refer to the pain team.
28. Within its complaint response letter, the GP practice said it expected Mr B to be in contact if he wanted it to carry out the referral plan. It is our view the letter already indicated Mr B wanted this to happen.
29. We have already identified there is no indication the GP practice should have sent the referral. It did not take any action to notify the neurosurgeon of this until 3 October, when Mr B chased the GP practice. It was only then the GP practice sent a letter to the neurosurgeon to explain it could not make the referral and the specialist needed to do this themselves.
30. There is an indication the GP practice did not act in line with GMC Good medical practice, and it could have acted earlier, in June. If there were any delays in sorting this, then it could have updated Mr B about it. This would have prevented any confusion and misunderstanding caused by the situation and delay.
31. Although the GP practice did not need to make the referral itself, its delay in acting on the letter contributed to a four-month delay. We understand this must be frustrating for Mr B and we appreciate he was in pain and discomfort at the time. Mr B seeks an apology, and the truth about why there were delays. He wants the GP practice held accountable and it to pay a financial remedy.
32. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
33. We understand this was a very frustrating time for Mr B and the delay in response to the request caused more stress. We are of the view the GP practice has reflected on this, apologised and has already done enough to learn from these events. It arranged to meet with Mr B on 15 July 2024 to try and resolve his concerns. The meeting note says a discussion took place about the referral. It apologised for the stress this has created. It wanted to do what it could to get his access to the right care.
34. It offered an apology about what happened and asked Mr B what would put right his concerns. We appreciate Mr B wanted to bring his complaint to the Ombudsman. We are of the view the GP practice acted in line with our Principles of Remedy and NHS Complaints Standards and tried to resolve his concerns. We do not consider it needs to take any further action.
Incorrect information in the referral dated 11 July 2024
35. Mr B said when the GP practice did eventually make the referral on 11 July 2024, it did not provide the information the provider needed.
36. To establish what should have happened with this referral, our adviser referred us to GMC delegation and referral guidance. It says the doctor should provide ‘relevant information about the patient’s condition and history and the purpose of transferring care and/or the investigation, care or treatment the patient needs’.
37. The GP practice sent a referral letter to the pain team at UCLH on 11 July 2024. Although it did not need to do this, it did so to prevent any further delay in Mr B’s care.
38. The referral attached the original letter from the neurosurgeon dated 2 June 2023 which explains the need for a pain team referral. It also included Mr B’s repeat medication and past medical history. Our adviser said the referral made by the GP practice was sufficient because the information for the referral was in the neurosurgeon’s letter.
39. We have seen emails sent between Mr B and the service manager at the pain team within UCLH. The initial emails from the service manager indicate a problem with the referral and missing information. She obtained this information from Mr B. He asked the service manager what information it used to triage the referral when it was accepted. The service manager confirmed the referral was accepted before she had uploaded the information Mr B provided. She also confirmed the clinician used the information in the referral to triage it. It was sufficient for him to do this.
40. There is no indication the referral letter needed any more information than what the GP practice included. The GP practice acted in line with GMC delegation and referral guidance.
41. We understand the frustration and stress these concerns have caused Mr B. It must have been very confusing when the GP did not make the referral and there was a dispute over who needed to action this. We are mindful of how important his complaint is to him and the difficult experience he has had. We hope our decision on what happened can bring some closure to his complaint about the GP practice.