A practice in the Liverpool area

4. Mr L complains about aspects of the care and service he received at the Practice between 2021 and 2023.

5. Mr L complains about how the Practice managed his referrals. He says the

• nephrology (kidney) referral was rejected because the Practice failed to manage his high blood pressure between 2021 and 2022 and that he was not tested for high blood pressure until 2022 • long covid referral had been rejected in May 2022, and he did not become aware until January 2023 when he contacted the clinic and • referral to Occupational Health for his chronic fatigue and request for walking aids, was not completed

6. Mr L says because of the failings there were delays in his care and treatment which caused him inconvenience, distress and frustration. Mr L also had to pay for his walking aids.

7. Mr L wants to achieve service improvement and a financial payment.

8. Mr L joined the Practice in October 2021. Prior to joining, his previous GP made a referral to the long COVID clinic.

9. Between March and October 2022, Mr L had raised blood pressure readings and underwent blood pressure monitoring.

10. In May 2022, Mr L's long COVID clinic referral was not accepted.

11. In December 2022, Mr L was started blood pressure medication.

12. Between March 2023 and June 2024, Mr L was referred to wheelchair services and community occupational health services. Unfortunately, these referrals were not successful.

Nephrology Referral

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 have done this and have not found any indications that something has gone wrong.

18. Mr L complains his nephrology referral was rejected in December 2022 because the Practice failed to manage his high blood pressure between 2021 and 2022 and that he was not tested for high blood pressure until 2022.

19. Mr L says this experience has left him feeling confused and undervalued as a patient. He also says because of his unmonitored blood pressure he experiences ongoing elevated protein levels in his urine.

20. In its response the Practice explained that in September 2022 it discussed Mr L’s blood pressure with him in September 2022 though at the time there was not enough evidence to prescribe blood pressure medication. It noted a blood pressure monitor was requested. It also noted there was protein in his urine and as such it said it ordered a protein creatinine ratio which is a laboratory test that measures the amount of protein relative to creatinine in a spot urine sample to evaluate kidney function.

21. The Practice noted Mr L returned in October 2022 with significant levels of protein in his urine and frequent urination and as such it submitted a nephrology referral. It explained the referral was rejected by the Nephrology Unit because the level of protein did not meet the minimum requirement for review by a specialist. It also said his kidney function test and glomerular filtration rate (eGFR) were normal which also contributed to the rejection. An eGFR is a blood test which measures how well kidneys filter waste.

22. During local resolution the Practice issued the nephrology rejection letter alongside its response. We have seen this letter as part of our investigation. We also provided a copy to our adviser. Our adviser explained the Practice did not provide blood pressure readings in its referral though said this was not necessary. Our adviser explained the rejection was not based on any action or decision of the Practice but rather the decision was made by the Trust in line with its referral criteria.

23. We recognise part of this complaint is also linked to Mr L’s belief that the Practice did not appropriately monitor his blood pressure. We have considered this below.

24. In February 2022, Mr L first raised concerns to the Practice about his blood pressure. The records indicate he had a series of blood pressure readings throughout 2022 which demonstrated raised blood pressure levels, above the expected range. The Practice arranged ambulatory blood pressure monitoring in May 2022. This is a test where a patient wears a portable monitor over 24 hours which takes regular readings during normal daily activity. The results showed an average reading of 144/84 mmHg which, our adviser explained, meets the threshold for stage one hypertension (high blood pressure).

25. In August 2022, Mr L attended a review at the Practice. The records indicate his blood pressure remained raised with additional readings in September 2022 following the same elevated pattern.

26. In October 2022, the Practice began a second round of ambulatory blood pressure monitoring. There was an average reading of 145/89 mmHg, indicating a continued elevated blood pressure. We have seen the Practice arranged a discussion with Mr L to discuss the results of his blood pressure monitoring. The records indicate Mr L chose to make lifestyle changes such as improving his diet rather than starting medication to manage his hypertension.

27. The Practice reviewed Mr L in November and December 2022 and it was noted that his blood pressure readings remained raised. The Practice started Mr L on ramipril (blood pressure medication) in December 2022.

28. We consider NICE NG136 is the relevant guidance that applies. NG136 provides guidance on identifying and treating hypertension in adults.

29. NG136 explains where a patient has a raised blood pressure reading of 140/90 mmHg or higher a clinician should arrange an ambulatory blood pressure monitoring to confirm hypertension. It continues that an ambulatory blood pressure of 135/85 mmHg or higher meets the diagnosis for hypertension.

30. NG136 says when a diagnosis of hypertension is established that a clinician should provide lifestyle advice and discuss treatment options whilst also considering a person’s overall cardiovascular risk and preferences before starting medication.

31. Our adviser explained once the ambulatory blood pressure reading in May 2022 indicated hypertension the Practice should have discussed the results with Mr L. We have not seen an indication this was discussed with Mr L earlier than October 2022.

32. We consider this was a short-coming, a one-off instance, where the care did not meet the expected standard. We do not consider this to have fallen so far below the expected standard of care to amount to a failing. This is because our adviser explained if the diagnosis of hypertension was discussed five months earlier it is likely Mr L would have chosen to make lifestyle changes as he did in October. Our adviser explained this means medication may have been started a few months earlier rather than when it was started in December.

33. Our adviser explained stage one hypertension develops over many years and any harm will only occur over long periods of time. Our adviser says it is not likely Mr L experienced any harm.

34. We understand this was a frustrating experience for Mr L who had concerns and questions about his blood pressure and elevated urine protein that he felt were unanswered. We hope Mr L is reassured by our explanations that there were no failings in the Practice’s management and monitoring of his blood pressure and urine function.

Long COVID clinic referral

35. 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 something has gone wrong.

36. Mr L complains that his long COVID referral was rejected in May 2022 for appointment non-attendance and he was not made aware until January 2023 when he contacted the long COVID clinic. He explains this was upsetting as he feels his GP should have informed him of appointments and rejections.

37. The Practice explained a referral to the long COVID clinic requires a blood test, chest X-ray and ECG (electrocardiogram) done within three months of the referral being made. An ECG is a non-invasive test which records the electrical activity and rhythm of the heart to diagnose heart issues. It explained this is why it requested blood tests to ensure all referral requirements were met before submission.

38. The Practice noted Mr L was being seen by the chronic fatigue clinic at the same time which was being managed by the same consultant. The Practice explained the long COVID clinic queried the need for a second referral. The Practice said it provided an explanation to the clinic to emphasis the reason for a second referral.

39. The Practice in its local resolution with Mr L said once a referral has been made it is the responsibility of the patient to engage with the secondary care service.

40. We have seen Mr L was referred to the long COVID clinic by his previous GP. The records indicate this was later rejected and he was discharged from the service for not attending a blood test appointment.

41. BMA and NHS England guidance on the interaction between primary and secondary care explains that once a referral has been made the receiving service holds responsibility for communication and managing appointments with the patient. Our adviser explained there is an emphasis on the importance of clear communication between services to ensure patients are not lost in the referral pathway.

42. The guidance does not place sole responsibility on either the Practice or patient in managing and engaging referrals. There is a focus on ensuring that patients are appropriately informed about their care.

43. We have carefully considered all the available evidence, including Mr L’s account, the medical records, and the local resolution notes. We have not seen clear documented evidence that the Practice failed to communicate the referral outcome or appointment details with Mr L. The Practice’s responsibility for the long COVID clinic referral ended once the referral was submitted to the clinic.

44. The records indicate Mr L was discharged due to non-response and failure to provide blood tests. We consider this suggests that communication attempts may have been made directly by the clinic, although the exact communication trail is not available in the evidence we have seen. This is because we have looked at the Practice’s correspondence with Mr L as the interactions with the clinic are outside our scope of investigation.

45. We recognise Mr L feels he was not adequately informed of the progression of his referral. We understand this referral was important to him and we have listened when he has told us that this has added to his frustration with how the Practice have interacted with his care and service. On balance, we have not seen sufficient evidence to indicate any failure in how the Practice engaged with Mr L’s long COVID clinic referral.

Occupational Health referral

46. 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 something has gone wrong.

47. Mr L complains that his referral to occupational health for his chronic fatigue syndrome (CFS) was not completed. He says because of this he was left without walking aids which resulted in him paying for this privately.

48. In it correspondence with Mr L and local resolution meetings the Practice said it did not feel he met the criteria for walking aids. It did note Mr L was provided with a form from the Practice’s reception to make a request for a wheelchair.

49. The records indicate the Practice referred Mr L to the community occupational health service in March 2023 alongside its referral to the wheelchair service. We have seen the wheelchair referral was rejected at triage. This is because the service said it does not provide powered wheelchairs to individuals who can mobilise independently.

50. Mr L’s occupational health referral was rejected in June 2024. This was because he did not meet the criteria for the service’s input. Instead, the service said a community mental health service could be more appropriate to provide Mr L with strategies to manage pain and fatigue.

51. Occupational health services and wheelchair services operate under specific eligibility criteria and commissioning arrangements. Referrals are assessed against these criteria, and services may be declined where these are not met. There is no guidance which requires a Practice to ensure acceptance of a referral, or to override eligibility criteria set by specialist services.

52. We consider there has been a misunderstanding in how the Practice managed Mr L’s request for walking aids. We understand he believes the Practice did not refer him and this has formed his belief that the Practice left him without walking aids.

53. We have not seen any indication the Practice failed to refer him. We hope our explanation provides Mr L with the reassurance his request was listened to and the decision was not made by the Practice.

54. We are sorry we could not provide Mr L with a more agreeable outcome. We thank Mr L for bringing this complaint to us.

1. We have carefully considered Mr L’s complaint about a GP practice in the Liverpool City area (the Practice).

2. We were sorry to hear of the circumstances of Mr L's complaint and the difficulties he faced with referrals and advocating for himself. We understand this has been a frustrating and challenging time for Mr L.

3. We have considered Mr L's complaint that the Practice inadequately managed his referrals for nephrology, long covid and occupational health, and we have seen no indication anything went seriously wrong. We understand how important this complaint is to Mr L, and we are sorry for any distress our decision may cause.