Urgent appointment request
16. 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 have done this and have not found any indications that anything has gone wrong with Mr R’s complaint.
17. Mr R said the Practice ignored his requests for an urgent appointment and did not understand the severity of his sleeping difficulties. Mr R says he wanted the Practice to prescribe him with diazepam. He told the Practice he had bought diazepam in the past.
18. The Practice stopped prescribing diazepam to Mr R, at the beginning of May because of its addictive nature. It arranged an appointment for Mr R to speak with the Practice about this decision for later in the month.
19. In mid May, Mr R telephoned the Practice requesting an urgent appointment as he was having difficulty sleeping. He requested a GP to see him the same day. Mr R said he wanted to be prescribed diazepam to help him with his sleeping difficulties.
20. The Practice triaged his request and sent a text message to him. The message said he needed to wait until his planned appointment.
21. Mr R telephoned the Practice again, requesting he a GP saw him the same day, as his request was urgent. The Practice said because there was no escalation of his symptoms since he last called, it was unable to put another urgent request through for triage.
22. The Practice advised Mr R to ring NHS 111 if he felt his request was urgent. It explained, he may be able to get a same day appointment, possibly within the hour.
23. In the Practice’s responses to Mr R’s complaint, it said it receives up to 300 requests per day for urgent appointments and only has a limited number of appointment slots. The Practice said it triaged Mr R’s request. It felt it was most appropriate for him to wait until his appointment.
24. NHS Modern General Practice Model requires consistent structured information is collected at the point of contact – to let the Practice know about symptoms, ask a question, make a request or follow up about something. It further says patients’ needs can be assessed and prioritised (triaged), allowing practice’s to provide patients with the most appropriate care or other response, from the right member of the practice team, including signposting or referring patients to other appropriate services.
25. When Mr R telephoned the Practice, he said he was unable to sleep, and he requested a prescription for diazepam. Our adviser said this would not meet the criteria for an urgent appointment or to get a call back the same day. This is because struggling to sleep is a constantly occurring issue, rather than a life threatening, acute or immediate danger issue.
26. NICE guidelines on diazepam say doctors should prescribe the lowest possible dose for the shortest period of time and review the patient regularly. It says treatment should not exceed two to four weeks.
27. Our adviser further explained diazepam is not something a GP would routinely prescribe over the telephone. They would always request an in-person appointment to discuss this first. Additionally, they said as Mr R was requesting a high dose of diazepam and was not on a regular prescription, these would be further reasons to request a face-to-face appointment.
28. Our adviser said in their view the Practice correctly triaged the call and referred Mr R to contact NHS 111 appropriately.
29. From what we have seen, we are satisfied the Practice acted in line with NHS Modern General Practice Model in telling Mr R to wait for his booked appointment.
30. We are further satisfied the Practice triaged Mr R’s request as indicated by the NHS Modern General Practice Model and decided it was more appropriate for him to wait for his scheduled appointment.
31. Considering NICE guidance on diazepam, and the information from our adviser, it is our view the Practice was unable to prescribe diazepam over the telephone. We believe it was appropriate for the Practice to request Mr R attended his in-person appointment.
32. As the Practice acted in line with this guidance, we have seen no indication of a failing when Mr R tried to make an urgent appointment.
33. We have also seen evidence the Practice signposted Mr R to NHS 111 services, should he feel he needed more support. We recognise the out of hours doctor did prescribe diazepam to Mr R and this has strengthened his belief that the Practice did not act correctly. We cannot comment on the actions of the out of hours doctor as this is not part of our consideration.
34. We recognise Mr R has concerns that the Practise did not see him for a same day urgent appointment. Mr R told us this caused his PTSD and anxiety symptoms got worse and caused him significant distress. We recognise this has been a very difficult experience for him.
Communication after NHS 111 referral
35. Mr R telephoned NHS 111 which assessed him during the call. NHS 111 advised Mr R to speak with a local service within two hours.
36. Mr R telephoned the Practice again. He said NHS 111 told him to speak to his GP within two hours.
37. The Practice sent him a text message which directed him to wait for his scheduled appointment.
38. Mr R says that the Practice ignored NHS 111’s referral and still refused to speak to him or take him seriously about his sleeping difficulties.
39. In the Practice’s complaint response, it acknowledged it received the NHS 111 referral. It explained the Practice triaged the referral and assessed it would still be best for Mr R to wait until his already booked appointment.
40. Mr R’s medical records support his account, and the NHS 111 referral advises him to contact a local service within 2 hours. We note it does not specifically refer him to his GP.
41. As referred to above, NHS Modern General Practice Model says patients’ needs can be assessed and prioritised (triaged), allowing practises to provide patients with the most appropriate care or other response, from the right member of the practice team, including signposting or referring patients to other appropriate services.
42. Our adviser explained that in their view, there were no red flags on the referral, such as suicidal intendencies or any urgency requirement. Mr R was ringing NHS 111 asking for medication for his sleeping difficulties and this was no different to the information he had provided the Practice earlier that day.
43. Our adviser said the Practice triage was in keeping with what they would expect to see. Mr R’s NHS 111 referral did not seem to be urgent to speak to or be seen by his GP the same day. Our adviser reiterated that his scheduled appointment allowed for the Practice to ensure it could safely, clinically assess his medication request.
44. Considering the guidance and the evidence we have seen, we are satisfied the Practice triaged the referral in line with NHS Modern General Practice Model. We are also satisfied the information Mr R said about his sleeping difficulties was not much different from the triage it had competed earlier that day. The pre-arranged appointment remained in keeping with guidance too.
45. As the Trust acted in line with guidance, we have seen no indication of failings.
46. We recognise Mr R had concerns that the Practice ignored the NHS 111 referral. Mr R told us this caused him significant distress. We recognise this has been a very difficult experience for him.
Did not follow correct procedures in a mental health crisis
47. Mr R telephoned the Practice again and made a further request for an urgent appointment. Mr R said at this point his mental health was unbearable and that he had suicidal thoughts. The Practice completed another urgent appointment request for triage by a GP. It advised him to contact NHS 111 or the crisis team if he was in a mental health crisis. The crisis team support individuals in mental health crisis. They offer support to individuals outside of hospital, usually in their home.
48. Mr R received a text message from the Practice which said it would not prescribe him with any medication. The Practice also said he would have to wait for his appointment. The Practice again directed Mr R to the crisis team and NHS 111 service for support with his mental health.
49. Mr R telephoned the Practice and said he felt the Practice was ignoring him. He also told the Practice he would be putting in a complaint.
50. Again, Mr R received a text message from the Practice saying it would not prescribe him diazepam. The Practice said he was to wait until his appointment. The Practice sent him a link to The Sleep Charity and advised him to speak with the crisis team in the meantime. The Sleep Charity provides support to individuals who have sleeping issues.
51. In the evening, Mr R telephoned NHS 111 again. It referred him to a local out of hours GP. The out of hours service prescribed Mr R a single dose of diazepam. It advised him to follow up with his GP.
52. Mr R said the Practice did not follow correct procedure for someone in a mental health crisis. Besides him telling them he was suicidal, he said the Practice still refused to see or speak with him for an urgent appointment.
53. In the Practice’s complaint response, it said it identifies the most suitable service for patients and their needs. When someone is in crisis and requires support for their mental health, the most helpful thing to do is to advise the individual to contact emergency services.
54. It says this is because these services are more equipped with the appropriate professionals and the Practice is not trained to deal with urgent mental health situations.
55. NICE guidance on risk of self-harm says where a patient is suicidal in primary care, use clinical judgment. If there is an immediate risk of harm direct them to the crisis resolution team.
56. Our adviser said when a patient tells their GP they are suicidal it is usual that the GP directs them to the crisis team. Our adviser confirmed the Practice gave Mr R the correct advice when they directed him to NHS 111 crisis team to get support for his mental health as during the call he said he has suicidal thoughts.
57. From what we have seen, the Practice followed correct procedures in linw with NICE guidance on risk of self-harm, when it directed Mr R to the NHS 111 crisis team for his suicidal intentions. The Practice also directed him to The Sleep Charity for further support with his sleeping difficulties. We consider the advice the Practice gave to Mr R was in line with NICE guidance on risk of self-harm. As the Practice acted in line with guidance, we have seen no indication of failings.
58. We recognise Mr R had concerns that the Trust did not follow correct procedures for someone who is in a mental health crisis. He found his experiences very distressing and now feels he cannot trust medical professionals. We hope our explanation offers him some reassurances.
59. Overall, we are satisfied the Practice has not done anything wrong and we will not consider Mr R’s complaint any further. We recognise how difficult it can be to make a complaint. We would like to thank Mr R for bringing his concerns to us.