Helen Salisbury: Advice and guidance for all referrals

This week I read a report in the Health Service Journal about a baffling plan to reform the process of referring patients to hospital outpatient clinics.1 Under the proposed new scheme a GP would no longer be able to refer directly to a consultant but would need to ask for “advice and guidance” first. At the same time, plans are afoot to enable patients to self-refer to hospitals.

When I first became a GP, after an admittedly circuitous route, I knew many of the doctors in the local hospital. I used to ring them up for informal advice if I was stuck with a clinical problem my immediate colleagues couldn’t solve, and I’d then refer to a named consultant, choosing them for their expertise but also their manner, matching doctor to patient. I now have no choice but to refer into an anonymous system. This has the advantage of evening out waiting lists, but it does so at the expense of patient choice.

The new proposed system—which is already running in some places—requires some back and forth between consultant and GP, in which the possible outcomes seem to be: (1) Yes, this is just the right case for my clinic; (2) I do want to see this patient, but first please organise these blood tests and scans; and (3) No, this patient doesn’t need to see me; I suggest you try this treatment instead.

It’s possible that patients in that third category will benefit from receiving treatment sooner without having to attend an outpatient appointment, but it’s also possible that rarer diagnoses will be missed or the patient will feel dismissed. And the second option seems to be once more dumping work on GPs, who are frankly fed up with being treated like community foundation doctors. It would require a transfer of resources into general practice to make it viable, so I hope that most referrals will just be accepted.2

Anyone who’s been in general practice for a while will remember a previous attempt to reduce outpatient waits, in which we were obliged to discuss all our proposed referrals with at least one other GP. It was a monumental waste of time and effort which, in our practice at least, had absolutely no effect on the number of referrals sent.

It’s hard not to feel cynical and see this latest proposal as just a ploy to make waiting list figures look better—after all, if you don’t accept the referral it can’t be added to the list. And it’s bizarre that, at the same time as a GP’s gatekeeping role gets beefed up with an additional hurdle to cross before a patient is added to the clinic list, NHS leaders also propose to open up opportunities for patient self-referral to secondary care. It’s beginning to look as though they trust the patients’ own assessment of their need for a hospital appointment more than that of the GPs.

Could mandatory use of advice and guidance work? A really slick IT platform, rapid responses with the patient kept in the loop, and time freed up for the extra work involved might make it possible (has anyone yet seen the magic GP tree?), although much of that additional effort would serve no useful purpose. Meanwhile, there are interesting medicolegal implications: if the GP says that the patient needs a specialist opinion but the specialist says no without seeing them, who is then responsible if the patient’s condition deteriorates?