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Independents' Day

Up to one quarter of GP referrals ‘avoidable’

Exclusive Up to 25% of GP referrals could be avoided through a combination of better signposting, education, pathway redesign and use of technologies, according to the authors of an audit of referrals carried out by a CCG.

The audit – led by two GPs at NHS Southern Derbyshire CCG – found 15% of GP referrals were inappropriate and could have been dealt with in primary care and another 8% were made before the condition had been fully explored, while a further 1% of referrals were classed as ‘bonkers’ by the authors.

However, they concluded that these avoidable referrals were as a result of ‘busy practices’.

Dr Komal Raj and Dr Callum McLean carried out the audit, in which all 20 practices in the locality sent in GP referral letters for the whole of November 2013 – a total of 1,995 letters weighing 42 kg.

As well as the 15% of inappropriate referrals, and 8% of early referrals, the audit also found 7% were were re-referrals, whereby patients had to be referred again after being wrongly discharged back to the GP.

The 1% of ‘bonkers’ referrals were ‘without focus, value or common sense’ – but these were most commonly the result of ‘proxy’ referrals whereby GPs were told by secondary care to make the referral.

The audit also revealed very marked variation in referrals among practices – with a 400% variation in the total number of referrals and a 2,000% variation in inappropriate referrals – which Dr Raj said showed a lot of the problems were down to some practices struggling with demand.

Dr Raj said: ‘I think it’s just busy practices, they are just so busy they have not looked at different ways to see patients or run their practices, and the end result is you get more referrals and admissions.’

He stressed most of the problems were due to poor communications or pathways and lack of education, and that the aim of the audit was to demonstrate where improvements could be made and put better systems and support in place.

Dr Raj added: ‘It’s not a case of telling GPs off, to say what they are doing wrong, because we’re all really busy and I know what happens, you’re busy, you’ve got a really full clinic and you just end up referring them.

‘What we are trying to do is find a solution to actually support GPs and practices. So one thing we’re looking at it is sending a GP into the practice, not in terms of simple triage but building up a relationship with the practice and looking not only at referrals but if there are issues with visiting rates, IT and all sorts of things.’

Readers' comments (33)

  • I agree 100% with the above.
    There are an infinite number of things that a GP, with appropriate training, COULD do. The fact is that there is neither the time for training, nor the time for doing all these things. The tendency for consultants ( or CCGs) to issue a list of demands before referral ( otherwise known as a protocol) purely to recuce their workload is unreasonable and should not be done for free outside normal general practice.
    I believe that investigations to establish the diagnosis and who to refer to are reasonable but we simply do not have the resources to shift all this work to primary care without more doctors.

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  • Not read it in detail yet but it appears some of what they are suggesting goes against NICE guidance/current practice.

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  • Let common sense prevail

    Anon 08.41.
    I think you make an excellent point. It is far cheaper for GPs to do everything they can prior to referral, and that is the only way NHS will survive, but the reason it is far cheaper is because we are not resourced for it. We work for nothing. There needs to ba a shift of resources to support extra work in primary care, but thus far that investment simply isn't happening, and the weather over the horizon is looking pretty grim!

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  • Try not referring something that might be cancer . IF it isn't cancer then de facto the referral is inappropriate . Either way we get screwed .

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  • This once again demonstrates what I have often said – there is no shortage of doctors willing to pour cr*p onto their fellow doctors.

    In this case, the well meaning GP authors have unwittingly and with great naivety provided NHS E, the Daily Hate Mail etc with plenty of anti-GP headlines. Even a cursory read of the headline and first paragraphs of the report here on Pulse, a pro-GP paper, read as anti-GP, so this is gold dust to the anti-GP organisations. How silly can you GPs get?

    Look at the headlines even in this pro-GP Pulse and then imagine the Daily Wail, NHS E, Hunt etc selectively choosing the bits they want: 25% of referrals need better education and technologies, it’s those errant stuck-in-the-mud GPs again; 15% were just wrongly made and should have been dealt with by the lazy GP; 1% were bonkers, presumably made by all those bonkers unsafe GPs.

    You and I, dear Pulse reader, read further down to find the real reasons the authors feel are behind those figures and they seem plausible and fair enough, and not anti-GP at all. But look at the bad headlines, that is all the anti-GP brigade will read and will promote widely to the public to add the mud they are slinging, and slowly little bits of it stick in the public conscience.

    Will you GPs please stop collaborating with CCGs, NHS E, Hunt etc in their fight against you? Stop letting your individual egos and desire for publicity rule your actions and start acting in the common good for a change.

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  • Drachula

    My practice's referral numbers were the best of the area, arguably, until a few months ago when pressure went up, new DES (or is it a LES) and reduced income meant I had less time and more to do. Therefore I am deliberately referring more so than at in don't have to worry about it any more.
    What a relief!
    If you pay my practice more I will change to 15 minute appointments, employ another doctor and refer fewer people. With the uncertainty about income, I can't plan the workforce and can't provide a better service.

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  • No one can get everything 100% right. So some will be not right. Add to this the Patient Charter right to a second opinion and 15% is not bad at all. The WHO found us THE VERY BEST GPs in the world. Hey, even Einstein did not know everything. I will take 15%.

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  • The really "bonkers" thing about this is that these sorts of studies have been going on for as long as I can remember (I've been a GP for 23 yrs). Nothing has changed and I'm sure nothing will change. This problem is what I'd put in the "impossible to control" pile.

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  • Indemnify us and we'll stop referring and stop prescribing!

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  • I think that patient choice is an important factor. sometimes, a referral doesn't seem sensible, but the patient is exercising his/her choice in wanting to discuss the problem with a specialist. ultimately, this is their right, I would contend.

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