Only the GP can issue a fit note beyond two weeks.
Reality
The treating clinician or team should issue an appropriate note for the expected recovery period, within professional scope.
Referrals & local services•National + local
Primary–secondary care interface: what should I actually do?
A practical guide to deciding whether a request belongs in general practice, clarifying clinical ownership and redirecting work safely.
Also known aswork bounced back from hospitalinappropriate workload transferhospital requests to GPsprimary secondary care interface
At a glance
Local variation likelyQuick answer
01
Who normally handles it?
Usually the clinician or service that identifies the need, unless an agreed pathway or shared-care arrangement assigns it elsewhere.
02
Is it mandatory?
Check urgency, the local pathway and whether responsibility has been explicitly agreed before accepting or redirecting the task.
03
Is consent needed?
Use relevant information and secure clinical channels; keep the patient informed about ownership and next steps.
04
Can the practice charge?
Usually not chargeable
Clarify ownership without creating a fight
This is not about reflexively saying “not my job”. It is about keeping the patient safe, avoiding duplicated steps and making sure the clinician or service that identifies a need acts on it where reasonably possible.
Six useful defaults
- If you request a test, you normally own the result.Ownership changes only through a clear, agreed handover.
- If you identify a related referral need, make it directly.Do not use the GP as a referral typist or the patient as a messenger.
- If you decide on treatment, start it safely.Provide an appropriate initial supply and a clear monitoring plan.
- If you are treating the cause of absence, issue the fit note.Cover the anticipated recovery period within professional scope.
- If A&G says “this patient needs to be seen”, avoid starting again.Use direct conversion where the pathway supports it.
- Local pathways and shared care still matter.These principles are a starting point, not a substitute for checking the actual arrangement.
Who normally owns the work?
Open the situation that matches the request. The short answer comes first; the source and important caveat sit underneath.
01Hospital asks the GP to order a test
- Who normally owns it?
- Usually the clinician or team that identified the need.
- What should I do?
- Check the local pathway or shared-care arrangement. If the test is for the specialist team’s own assessment or monitoring and no pathway assigns it to primary care, ask that team to arrange it and tell the patient what will happen.
- Why?
- The Hampshire and Isle of Wight agreement says clinicians should arrange the investigations their patients need. National interface guidance supports direct requesting when follow-up ownership is clear.
02A hospital investigation is still pending
- Who normally owns it?
- The team that requested the investigation, unless another clinician has explicitly agreed to take over.
- What should I do?
- Do not assume a discharge letter transfers ownership. If the result or follow-up plan is unclear, contact the initiating team and document who is responsible.
- Why?
- Unclear result ownership is a patient-safety risk. Escape the Tape states that pending secondary-care investigations remain with the initiating clinician unless responsibility is explicitly agreed otherwise.
03A specialist wants another specialty involved
- Who normally owns it?
- The specialist who identifies a related or urgent clinical need.
- What should I do?
- Ask Specialist A to refer directly to Specialist B and keep general practice informed. GP assessment may still be appropriate when the new issue is genuinely unrelated to the specialist episode.
- Why?
- Direct onward referral avoids using the patient and GP as administrative intermediaries. Escape the Tape cites the NHS Standard Contract for related or urgent onward referrals.
04The referral reached the wrong specialty
- Who normally owns it?
- The receiving provider, where safe internal re-triage or reallocation is available.
- What should I do?
- Ask whether the existing referral can be redirected internally rather than returned solely for a replacement GP referral. The provider should keep the patient informed.
- Why?
- Escape the Tape challenges the idea that changing specialty within e-RS always requires the GP to start again.
05Advice & Guidance says the patient needs to be seen
- Who normally owns it?
- The specialist service should normally complete the next step where the pathway allows.
- What should I do?
- Ask for the A&G request to be converted directly into the required referral or procedure instead of submitting the same information again.
- Why?
- A&G can streamline care. The problem is the unnecessary extra step, not A&G itself. The local agreement supports direct conversion, and national guidance references the e-RS Convert to Referral function.
06Secondary care starts a medication
- Who normally owns it?
- The clinical decision-maker starts treatment and provides a safe initial supply.
- What should I do?
- Look for the indication, dose, duration, monitoring and intended handover. Do not take on unfamiliar or specialist prescribing until responsibility and any shared-care requirements are clear.
- Why?
- Escape the Tape says an appropriate outpatient supply is typically around 28 days when clinically suitable and cites NHS Standard Contract SC11.9–11.11. Formal shared care is a separate, agreed transfer.
07The patient needs a fit note after hospital care
- Who normally owns it?
- The clinician or team treating the condition causing the work absence.
- What should I do?
- Ask the treating service to cover the anticipated recovery period—for example, six weeks after surgery—rather than issuing two weeks and directing the patient to the GP.
- Why?
- Appropriately involved doctors, nurses, pharmacists, physiotherapists and occupational therapists can issue fit notes within their scope. The local agreement also asks treating teams to cover the predicted illness period.
08Secondary care identifies a need for district nursing
- Who normally owns it?
- The team identifying the need, where the local community pathway accepts direct referral.
- What should I do?
- Ask the hospital or clinic to use the direct community referral route rather than making the GP reproduce its assessment.
- Why?
- Escape the Tape supports direct secondary-care referral to community nursing teams, subject to locally agreed criteria.
09The patient is discharged after a DNA
- Who normally owns it?
- The provider must make and document a clinically appropriate decision; not every DNA means automatic discharge.
- What should I do?
- For a vulnerable or high-risk patient, check whether reasonable attempts were made to contact or rearrange and whether risk was reviewed. Escalate concerns through the provider or local interface route.
- Why?
- Escape the Tape cites NHS Standard Contract requirements for reasonable contact and rearrangement before discharge is considered. Discharge can still be appropriate after clinical review.
10A clinic letter says ‘GP to consider…’
- Who normally owns it?
- Responsibility remains unclear until the requested action and handover are explicit.
- What should I do?
- Check what is being requested, why, by when and under which pathway. Seek clarification when the action is vague, clinically inappropriate or outside an agreed arrangement.
- Why?
- The local agreement asks for a clear, highlighted GP-actions section. A one-line instruction is not automatically an agreed transfer of clinical responsibility.
11A message needs rapid clinician-to-clinician clarification
- Who normally owns it?
- The clinicians and services involved should use an approved direct route.
- What should I do?
- Use an NHS-approved option such as a clinical advice line, secure messaging, shared inbox, liaison service or NHS Service Finder contact rather than creating a patient appointment just to relay information.
- Why?
- Escape the Tape says secure real-time communication can complement formal clinic letters; it does not replace necessary clinical documentation.
Seven common assumptions to unlearn
Hospital doctors cannot refer directly to another specialist.
Reality
Related or urgent onward referrals should generally be made directly, with the GP kept informed.
Hospital investigations become the GP’s responsibility at discharge.
Reality
The initiating team retains responsibility unless an explicit handover has been agreed.
The GP must order bloods needed for the next hospital clinic.
Reality
The team identifying a test for its own management should normally arrange it unless an agreed pathway says otherwise.
A&G says the patient needs an appointment, so the GP must re-refer.
Reality
Where the pathway supports it, secondary care should convert the request directly to a referral.
District nursing referrals have to come from the GP.
Reality
Secondary-care teams can refer directly where local community pathways allow.
Two DNAs automatically mean discharge.
Reality
Providers should make reasonable contact attempts and use clinical judgement before discharge.
A six-step check before accepting or redirecting work
- 1Safety first
Is this urgent or could redirecting it now cause harm? Manage immediate risk before resolving the interface problem.
- 2Find the origin
Was the task generated by another clinician as part of their assessment or treatment?
- 3Check the pathway
Does a current local pathway or formal shared-care agreement assign it to primary care?
- 4Check the principle
If not, does local or national interface guidance keep it with the originating service?
- 5Confirm the handover
A letter saying ‘GP to…’ is not necessarily an agreed transfer. Clarify the task, timing, monitoring and responsible clinician.
- 6Resolve the pattern
Protect this patient, document the outcome, then raise repeated workload transfer through the practice, PCN, LMC or ICB route.
What primary care is still responsible for
Interface guidance is not an excuse to avoid work that genuinely belongs in general practice.
- Assess and treat appropriately before referral.
- Make the clinical question and reason for referral clear.
- Include sufficient, relevant clinical information.
- Follow reasonable local pathways and complete genuine pre-referral tests.
- Optimise long-term conditions before planned surgery where appropriate.
- Help patients wait well and manage ongoing primary-care problems.
- Use Advice & Guidance when it adds value.
- Keep patients informed and make it easy for clinicians to contact the practice.
Local consensus agreement
Hampshire & Isle of Wight
The Hampshire and Isle of Wight Way is a shared local agreement, not a statement that every point is a statutory duty. It can be cited when clarifying responsibility across local services.
The agreement also supports direct onward referral, A&G conversion where appropriate, secondary care arranging the tests it requires, realistic fit notes, clear GP-actions sections in letters, an appropriate initial medication supply and honest next-step timelines for patients.
Open the local agreementRedirect the task, not the patient
Keep the message short, specific and collaborative. State who should act, what needs arranging and which agreement supports the request.
Investigation“Thank you for your letter. As this investigation is required for your ongoing specialist assessment, please could your team arrange it directly, review the result and communicate the plan to the patient, in line with the local interface agreement?”
Onward referral“Thank you. As your assessment has identified a related need for [specialty], local and national interface guidance supports direct specialist-to-specialist referral. Please could this be arranged directly and the patient kept informed?”
Medication“As this treatment was initiated by your service, please could you provide an appropriate initial supply and document the indication, monitoring and intended ongoing prescribing arrangements? We can then assess whether transfer to primary care is appropriate.”
Official guidance
For your eyes only
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Local notes
In Hampshire and the Isle of Wight, use the 2025 local consensus agreement alongside current pathways. Elsewhere, check the equivalent ICB or provider interface agreement before relying on local detail.
Content record
Content information
- Status
- Sources checked
- Applies to
- England
- Created
- 23 Jul 2026
- Last updated
- 18 Sept 2026
- Sources checked
- 18 Sept 2026
- Next review due
- 18 Mar 2027