Intended for healthcare professionals

Analysis And Comment

Patients are not commodities

BMJ 2006; 332 doi: (Published 06 April 2006) Cite this as: BMJ 2006;332:846
  1. Iona Heath, general practitioner (iona.heath{at}
  1. Caversham Group Practice, London NW5 2UP

    Referral management centres have been set up in an attempt to control the flow of patients from generalist to specialist services.1 Those proposing and creating such centres seem to view a referral as a simple administrative transaction, whereas those working in primary care know that a successful referral is a much more complex and challenging phenomenon.

    Referrals cannot be understood simply in terms of demand. Many patients have to be persuaded to accept referrals and this requires painstaking and careful negotiation within which wide-ranging fears are explored and discussed. The referral process must be able to respond not only to expressed demand but also to unexpressed need.

    Referrals occur either because the diagnosis is not clear or because more technologically demanding investigations or treatments are required. When a patient requests or is offered a referral, the fear implicit in almost all consultations escalates: fear of a serious diagnosis or of painful or embarrassing procedures. Fear can be held within a trusting relationship between two known individuals and, in an institution such as the NHS, an interlocking chain of human relationships both creates and sustains trust. Referrals need to exploit rather than disrupt this chain of relationships.

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    Meeting patients' needs

    A traditional referral has the form of a personal introduction; referral management centres are the equivalent of dating agencies. General practitioners listen every day to patients recounting their experience of specialist services and, as a result, practices build up a substantial knowledge of local services and are able to tailor these to a patient's particular needs by making a deliberate and considered choice of specialist service.

    The government's latest health white paper declares the now familiar intention of “fitting services round people not people round services.”2 Yet, as so often in the health service, referral management treats people instrumentally as the means to a larger purpose and obliges them to conform to the values and aspirations of those exerting power and control.3

    Worse, referral management seems to represent a further stage in the relentless commodification of health care.4 It is an attempt to carve out yet another standardised unit of healthcare delivery that can then be released into the market economy as a potential source of commercial profit. Davies and Elwyn rightly draw attention to the lack of evidence for the cost-benefit of referral centres but it is easy to envisage their rapid privatisation.

    Collaboration not separation

    Organisers of health care seek to use primary care practitioners as gatekeepers to control the use of specialist services. In contrast, those working in clinical care see the interface between specialist and generalist care as the means of maximising the effectiveness of both. Generalists can work to the limits of their knowledge and skill only if they can refer easily and promptly to their specialist colleagues when those limits are reached. Specialists can only use their skills maximally if they are enabled to work with a highly selected population for whom their particular skills are appropriate.

    The organisational perspective seeks to put barriers in the way of referral; the clinical perspective needs to minimise any such barriers. Referral management centres are clearly intended to reinforce the barrier and, as such, run the risk of undermining not only the safety of patient care but also the complementary nature of the generalist and specialist roles and their consequent cost effectiveness.


    • Competing interests IH is a general practitioner whose work would be directly affected by the introduction of referral management centres.


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