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At the heart of general practice since 1960

The mad referral merry-go-round

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What a merry dance the NHS leads us. Not the Strictly Come Dancing shimmy-in-sequins type, but a brutal, grinding, interpretive number that can only end badly.

I met up with some friends from medical school recently. One of them is now an interventional radiologist – one of the new breed of all-singing, all-dancing radiologists who can fix tricky things with just a very long needle and an expensive scanner. But like the rest of us, he was complaining about the system.

‘So I saw a patient today who has waited eight months.’ Cue much sympathetic nodding. ‘He went to his GP in February with back pain and turned out to have some weird venous malformation pressing on a nerve. The radiologist who reported the scan suggested referring to me. But the GP isn’t allowed to refer into a neighbouring CCG without a local consultant seeing the patient. So the GP referred him to his friendly neighbourhood neurosurgeons, even though he knew they don’t do the type of procedure the patient needed. They then referred the patient to my hospital’s neurosurgeons because they aren’t allowed to refer to another specialty. After seeing the patient, those kind neurosurgeons sent him to me.’

We all shook our heads, imagining the despair the patient must have felt while being passed like a parcel.

But the story was not finished. ‘I did the procedure today. Hopefully he is sorted. But I need to review him in a few weeks and I can’t do that without a new referral from his GP.’

I didn’t go to medical school to do paperwork all day.

This stunned me into silence. The specialist has effectively discharged the patient and written back to the GP asking for a re-referral for follow-up. With himself. Except the GP is not allowed to refer directly to him. The merry-go-around will begin again, and the patient – who has already waited eight months – will probably be spending that time on a cocktail of painkillers, with a sick note.

This is bureaucracy gone mad. It is infuriating enough to have a contract where consultants in the same hospital cannot refer to each other. But now consultants aren’t even trusted to follow up their own patients?

We get ridiculous letters all the time saying: ‘Dear GP, this patient with COPD developed CKD 4 while a respiratory inpatient. They were reviewed by the renal team while an inpatient, and need renal follow-up, but I am not allowed to arrange this. Please refer to the renal team.’ As if GPs have nothing better to do than be secretaries.

It is this type of maddeningly frustrating, disjointed thinking that we face every day. I didn’t go to medical school to do paperwork all day. I don’t get excited by dictating a good letter. With the precious little time I have, I want to be seeing patients and treating actual pathology.

Where did doctors treating patients get forgotten in all this? Will anyone ever remember that’s supposed to be our job?

‘Oh, no,’ goes the refrain from our leaders in Skipton House. ‘Just keep referring!’

 Dr Zoe Norris is a GP in Hull

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Readers' comments (16)

  • Very tough call - completely agree with you, but how do we also stop the gaming of tariff that happens when we give consultants unfettered access?

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  • The answer is to totally destroy the internal market one way or another.I can also see the return of the"see and do the needful"letter maybe including a copy of the said consultants letter.The system is financially and morally bankrupt already so don't sweat on bringing it down.

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  • My referral letter for some events now comprises; Dear Dr, "Please see. Letters enclosed" Yours sincerely.

    And courtesy of Laurence Buckmans excellent article I will be adding a PS. "This letter was produced solely because of the internal market’s transactional costs, it serves no clinical purpose and has added unnecessary delay to the patients treatment/diagnosis".

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  • I spoke to a GP working in Salford

    the CCG there has completely banned all "please can GP refer" workload. Hospitals have to refer internally now.

    Im not sure how they've managed that but it sounds great!

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  • Why don't our consultant colleagues chip in with some clinical leadership here? When I was a junior (in the late 80s I admit), the Consultants were Lions, now they are minions. At what point did either party (Consultants or GPs) give consent to this farcical situation. It is about time that we stood together on this: there is a fake anxiety about the DoH / NHSExe which is just a house of cards. If pressed, I suspect the GMC would have to come down on the side of the clinicians purely on the basis of Good Clinical Practice... or have they produced another prissy booklet called something like "Good Practice: obeying what Civil Servants dreamt in the bath one day".

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  • In Wales we don't have an internal market but somehow seem to regularly be writing to hospital colleagues asking them to refer direct to the specialist the patient needs to see and not bouncing back to the GP who initially referred. When it is don't right, it is done well and quickly though!

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  • This is what happens when the 2B + 1Cs start running the show and tell 4A* how to work.

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  • This is sickening!!! To think this lunacy actually goes on in the UK??

    No wonder GPs are retiring or emigrating, who would train for 10years to be a referral monkey

    Its sad to see just how much of a third world country the UK has become with all its red tape rules and regulations;

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  • Anon 9:55pm - nothing to do with intelligence - most at the DH are intelligent (plenty of straight-As and Oxbridge firsts) but just not willing to listen to what actually happens on the ground (forgetting that wisdom requires experience, listening and humility just as much , if not more than, academic intelligence, perhaps because they are so 'bright'). Oh, and I did get the grades to have gone into medicine had I wanted to.

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  • Again I agree the only real answer is the liquidation of the catastrophically wasteful fragmenting failed internal market and return to the early 80's clinically led integrated service so returning the managerial cult to its correct supportive not autocratic role..the latter have tripled due to market using madness

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