South East London Integrated Care Board

4. Ms K complains about the policy implemented by the ICB, previously Bromley CCG between 2017 and 2022. She complains that this policy forced primary care givers (GPs) to refer her through physiotherapists to secondary care givers (hospitals).

5. Ms K says this policy caused delays in her receiving a diagnosis of hyperparathyroidism which she received in 2022. She says she was forced to see a physiotherapist by the referral pathway and other unnecessary referrals. She wants an apology, service improvements and financial compensation.

6. Ms K attended her GP on numerous occasions between July and September 2015. Her GP ordered blood tests which showed raised levels of calcium in July and September 2015. On 24 September the GP also tested her parathyroid hormone (PTH) level which was reported as within normal range. The GP measured her calcium levels again on 4 March 2016 and they were still raised.

7. Ms K attended her GP on 24 August 2017 and asked them to refer her to a specialist as she was experiencing numbness in her hands and feet. Her GP made a referral to a musculoskeletal (MSK) physiotherapist. Ms K’s GP referred her to a consultant neurologist on 2 August 2018 in relation to numbness in her hands and feet. The neurologist saw her on 23 November and noted there was nothing abnormal with her nerve conduction study results.

8. Ms K attended her GP on 24 October 2019 with pain in her arm. The GP recommended she self-refer through the MSK service. She did this and the MSK Team saw her on 8 November. The MSK team arranged an MRI scan. Ms K’s GP referred her to the MSK team again on 2 March 2020 after she was seen by a private rheumatologist on 28 February.

9. Ms K’s GP requested blood tests on 11 November 2021 as part of an investigation into her ongoing neurological symptoms. This was carried out on 3 December and found Ms K’s calcium level to still be raised. Ms K says she was not told about this until July.

Referral 12. Ms K complains that the ICBs referral policy meant that she had to be referred to MSK physiotherapists before being referred on to hospital specialists. She says this delayed her diagnosis of hyperparathyroidism which she told us she received in July 2022.

13. Hyperparathyroidism is a condition where the parathyroid glands make too much parathyroid hormone. ELSEVIER explains that hyperparathyroidism is the most common cause of high calcium levels (hypercalcemia). NICE guidelines say ‘albumin-adjusted serum’ calcium levels in the blood should be repeated if levels are found to be above 2.6mmol/l. The guidelines also say to measure parathyroid hormone (PTH) if these calcium levels are above this level on two separate occasions. Cleveland clinic says normal range for PTH levels are between 10 and 65ng/l.

14. Ms K attended her GP on multiple occasions between July and September 2015. Her calcium levels were measured as 2.68mmol/l on 21 July, 2.7 on 17 September and 2.69 on 24 September. On 24 September the GP also asked for her PTH level to be tested and this measured 48ng/l. Ms K attended her GP on 15 October. In this record it says she had moderately raised calcium levels, and this should be tested again in six months.

15. SEEEG guidance says that if a patient has high calcium and high PTH then hyperparathyroidism is the likely diagnosis however if PTH is low or normal then another diagnosis is more likely. NICE guidelines say to seek advice from a specialist if PTH is above the midpoint and primary hyperparathyroidism is suspected.

16. Ms K’s calcium levels were measured again on 4 March 2016 and found to be 2.61mmol/l. Her PTH was also measured and found to be 65ng/l, at the upper limit of the normal range.

17. Based on NICE guidelines it appears at this point because her calcium levels were still raised above 2.6mmol/l and her PTH was higher in the range at 65ng/l, Ms K needed to be referred to a specialist in endocrinology which is a specialism that investigates and treats hormone and gland conditions such as hyperthyroidism.

18. The ICB told us that an endocrinology referral can be made directly to the specialist team or department in secondary care (a hospital) rather than being sent to triage.

19. Ms K attended her GP on 24 August 2017 for referral to a specialist for her symptoms of numbness and pain as she was concerned it make be a condition with her bones or spine. The GP referred her to be seen by the MSK centre. A letter from 10 April 2018 says she did not attend her appointment on 13 March, and it had not heard from her. It discharged her back to her GP for re-referral if necessary.

20. The ICBs rheumatology (MSK) referral policy at the time required patients to be reviewed by a physiotherapist for assessment at the MSK centre before they could be referred to specialists at a hospital. It appears this is what the GP did following additional symptoms of numbness and pain and Ms K’s concerns about this.

21. Based on the evidence that we have seen, it does not appear that the ICB’s referral policy delayed Ms K’s diagnosis of hyperparathyroidism as she has suggested. It appears in line with NICE guidance she could have been referred directly to see a specialist in hyperthyroidism at the hospital in 2016 due to her blood results, but this did not happen.

22. It is understandable that Ms K is frustrated that she did not receive her diagnosis of hyperparathyroidism earlier and we appreciate the distress and pain she has experienced due to the time it has taken. It appears Ms K could have been referred to a specialist in hyperthyroidism when her raised calcium and PTH levels were discovered in 2016.

23. When Ms K asked to be referred to a rheumatologist this was done through the ICB’s pathway which first includes an assessment in the MSK centre by a physiotherapist. We have not seen that the ICB’s referral policy prevented a referral to an endocrinologist. Therefore, we will not be taking further action to investigate this complaint and hope our explanations give Ms K some reassurance about what the ICB did.

1. We have carefully considered Ms K’s complaint about South East London Integrated Care Board (the ICB). We were sorry to hear of the concerns Ms K had regarding its referral policy which she told us meant her hyperparathyroidism was not discovered at an earlier time. We can clearly see from what she has told us that this has caused her a lot of distress and she has been left frustrated with the actions of the ICB.

2. We have carefully considered all the evidence available to us and we have seen no indication that anything went seriously wrong. We have seen the ICB followed the correct referral process based on the referrals that Ms K’s GP made and the fact that there was an option for the GP to refer her directly for endocrinological investigation. Therefore, we will not be investigating the complaint further.

3. We are sorry for any additional upset this may cause and hope our explanations below explain how we have fully considered this and why we think nothing went seriously wrong.