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All GP referrals should be subject to clinical peer review, says NHS England

BMJ 2017; 358 doi: (Published 01 September 2017) Cite this as: BMJ 2017;358:j4106

Re: All GP referrals should be subject to clinical peer review, says NHS England

I read this article with despair, and can answer David Brooks' question as to whether good GPs refer less, or bad GPs refer more. I studied this nearly 25 years ago, analysing one year's worth of new patients (over 600). It was apparent that there was a tiny number of GPs who regularly made what I considered to be bad referrals (not infrequently because they hadn't examined the patient), but equally there were excellent GPs whose referrals sometimes seemed unnecessary.

And the word "seemed" is vital here. How do you define an unnecessary referral in the first place? Is it one that any competent GP should have been able to deal with? Is it one made to the wrong specialist? Is it a reassurance-seeking referral which won't require any treatment? It it a referral that the patient has insisted upon (as is their right)? And who should assess necessity? Should it be a GP, whose level of ignorance may be the same as their peer? Or, in my specialty, a physiotherapist - which happened in my locality? Or a specialist? And how is it acceptable to make an assessment on a referral letter which may be lacking in significant detail when you haven't seen the patient, haven't asked the questions that the GP should have asked, and have not examined the patient?

I came to the conclusion that no referrals were unnecessary referrals. There were bad GPs, but at least if they referred a lot then the patients would be safe.

All of these questions must be addressed, as well as the serious issue of who will carry the can when a referral is unnecessarily delayed. My basic premise that if a GP wants a specialist referral for whatever reason then they should have it. Doctors are professionals; to demean them by requiring a cross-check on all their work is, frankly, disgusting and unprofessional, and the benefit gained from blocking referrals.

There is undoubtedly a normal distribution of referral patterns in numerical terms. What might be sensible and interesting is if managers made an investigation into both ends of the l distribution to discover why some GPs under-refer. Patients are more at risk from that than from being sent to hospital too quickly. I am sure it is not only I who thought "If only they had been sent up earlier".

If GPs are, effectively, having to do their work twice the pressure not to refer will become intense and risks will be taken. This is in no-one's interest, and NHS England should think again.

Competing interests: No competing interests

14 September 2017
Andrew N Bamji
Retired Consultant Rheumatologist