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GPs go forth

GPs' supposed 'three strikes' rule on referrals is a complete myth

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Jeremy Hughes, chief executive of the Alzheimer’s Society, has some explaining to do.

I’m not one for singling out the behaviour of one individual, but his comments about GPs at the King’s Fund on Tuesday were a real low point in an otherwise excellent conference on dementia.

On the basis of the comments of an unnamed ‘GP friend’, Mr Hughes claimed that GPs operate a ‘three strikes and you’re in’ policy whereby they were ‘taught’ to only refer a patient after seeing them at least three times in order to ‘balance the books’.

Pulse readers won’t need me to tell them how wildly misleading this is. I can’t say whether or not Mr Hughes was told this by a GP.

But that claim is so plainly wrong that it beggars belief that Hughes could deliver this cynical overstatement as truth to a packed room of delegates, all of whom are trying to improve the care of patients with dementia.

Seething in my seat, I challenged Mr Hughes about it on Twitter, stating that it was simply not true that GPs were ‘taught to see someone three times before they refer’.

He replied: ‘Good GP training improving, but too many people still report repeated visits to GP and much distress before diagnosis referral’

So now he asserts that GP training is ‘improving’. But does he know anything about that subject either?

Has Hughes ever visited a VTS scheme to see how we are trained? Would he like to visit mine?

Would he like me to make sweeping, ill-informed comments about how Dementia Navigators are trained by the Alzheimer’s Society?

No, I suspect he wouldn’t, and nor will I – because I know nothing about it.

Whether or not to refer a patient to secondary care is a complex business involving ethics, the balance of benefits and harms, clinical urgency and patient preference. GPs have never been taught to ration care on the basis of his ‘three strikes’ assertion, and it is ludicrous to claim otherwise - as a GP trainer for over 10 years and a Programme Director for nearly five years, I consider myself qualified to say so.

Yes, there are times when GPs could and should have referred sooner, of course. But this is not the same as saying we are taught to deliberately delay a referral in order to balance the books.

If we are to improve the care of people with dementia, it would really help if Mr Hughes could stop making wild claims about the inadequacies of GPs, and start listening to us instead.

Sadly, he shows no sign of doing this. In his closing remarks, he criticised his own GP practice for installing a self-check-in machine at reception, declaring it to be ‘most un-dementia-friendly’, since patients with dementia would struggle to operate it.

Had he asked any of the GPs in the audience, we could have told him that patients with dementia can still check-in in the usual way.

Moreover, we could also have told him that since the introduction of these machines, practices have experienced shorter queues at reception - meaning they have more time to help someone who might have dementia.

But he didn’t ask us, did he?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.

Readers' comments (8)

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  • I am hugely concerned about the influence the CEO of Alzheimer's Society has and the mixed messages he delivers. I fear that this is heightening and not reducing stigma.

    I share Dr Brunet's discomfort in singling out any individual.

    The CEO of Alzheimer's Society has been inconsistent, in fact virtually volte-face, when it comes to the messages given to the public on the established science of acetyl-cholinesterase inhibitors.

    It is time for us to ask if "Big Charities" should be in the driving seat?

    Our ageing population deserve the more rounded understanding of pluralistic science.

    My reading of much that comes from the Government on Dementia is that it carries the language, "understandings" and "fighting talk" of the Alzheimer's Society.

    I plea for a more scientifically, ethical and pluralistic approach. To completely isolate ageing and disease needs a brave or foolish mind. Or should I say brain?

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  • I see that he earns twice as much as the average GP. Vide Guido Fawkes blog.

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  • First off all I live with AD and don't care what Mr Hughes said. The sad truth is the medical community needs to get of there high pedestal and know how to treat a patient.. It took me 10 years to get a diagnose after so many test.

    While I am aware of some great doctors out there. The sad truth is that is a very small number. If you want to talk more about this you can reach me thru my web site.I will be more then happy to give you the real world view.

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  • Mr Ellenbogen. I'm sorry but the statement that there are very few great doctors out there is unsubstantiated. Maybe in your situation this has been your experience but i'm not sure you can generalise that to the whole profession. At present we are simultaneously being criticised for referring too many patients for dementia assessment at the same time as taking too long to refer patients! And your last sentence is something that should grace the comments section of the daily mail rather than this website that is 'intended for health professionals only' Note to pulse - when are you going to validate that people registering on this site are health professionals and not people with an axe to grind or DM journos

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  • Hi there, thanks for your comment. Only healthcare professionals are able to comment on the site, and this is how it will remain.

  • Michael Ellenbogen
    I deeply resent your ignorant and offensive comments. I have spent my entire day helping people with problems which range from the care of new borns, through every age group including the elderly and demented. I've seen people with mental illness today and people with diabetes, I've helped arrange care for poor folk in the final stages of death from cancer and I've done several routine checks on 6 week old babies for good measure. I've visited a number of people in their homes who were too ill to come the surgery, one of whom I'm concerned may have had meningitis ...I've signed several hundred prescriptions and I've been verbally abused by several people who didn't get what they wanted despite my having done everything I possibly could within the limits of the resources I had available to try and make them happy. I've come home emotionally shattered and truly exhausted and to de-stress I pored my heart out to my unfortunate partner who isn't here over the phone....and I sit down at the end of the day and read the comments section of PULSE to see some mean spirited inward looking individual unfortunate enough to have developed dementia slagging off my profession. What have YOU done today Mr Ellenbogen to help your fellow man? What have you done to ease the suffering of those around you today? And why have you come onto a web site intended for health professionals to moan and spread bad feeling amongst people who's entire reason to go to work is in order to try and help other people. Good luck to you my friend but please have a heart and keep your bad feeling to your self.

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  • Mr Ellenbogen you LIVE in America. This is a BRITISH publication/website. Dont paint British doctors with the same brush as US doctors.

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  • For GP revalidation and Appraisal Click:

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