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Rushing to reduce referrals is dangerous

Letter from Dr Kamal Sidhu, Blackhall, County Durham

These are desperate times for the NHS so the CCGs are trying to ‘live within their means’ which essentially means some service cuts or redesigns. Another pressure is to reduce activity i.e. referrals and admissions from primary care into secondary care.

Primary care clinicians are stuck between a rock and a hard place

Referrals are an important yet complex role of GPs and are made for a variety of reasons including help with diagnosis or management as well as for reassurance of patients and clinicians alike. There is little argument that use of skill mix and community pathways etc must be encouraged but if they have adequate capacity. There is also benefit in shared decision making and managing patient expectations where necessary but there are pitfalls and potential for harm especially when the referrals are micromanaged or there are targets set to achieve blanket reduction in total number of referrals. Rightly, the BMA has historically opposed the target approach but it is all too common now that the commissioners are having to set referral reduction targets and worse still, the practices are incentivised to cut down on the referrals.

On the other hand, GPs are often derided for delaying referrals for conditions varying from cancers to endometriosis to dementia and mental health. The public is also given conflicting messages resulting in raised expectations about referrals. Guidelines such as from NICE push us towards increased referrals failing to take into account the resource crunch.

Primary care clinicians are stuck between a rock and a hard place. If they are asked to reduce referrals, they take on a lot more uncertainty. This potentially means missed or delayed opportunities for diagnosis and care. This also means additional stress and risk of burnout for an already overstretched workforce. There is also a small number of referrals made to ‘share the burden of management’ and frankly speaking, we do not have the capacity to absorb any of the additional burden.

I worry that such restrictions can result in reduced referrals around nonspecific or undifferentiated symptoms, some of which often evolve into a significant or even serious diagnosis especially given multimorbidity and poor predictive value of many investigations in primary care. We cannot ignore the fact that a significant majority of cancers are diagnosed outside the two week/suspected cancer diagnosis pathways, sometimes based on so called ‘inappropriate’ referrals.

Simplifying referrals to numbers unfortunately fails to take into account the patient, doctor relationship as well as many subtle but vital factors such as atypical presentations and nonverbal cues. The local context can not be ignored.

In the end, none of our commissioning colleagues will come to our defence in case of a delayed or missed referral.

The problem with incentives

Whilst we know that incentives do have a role in improving quality of referrals and in encouraging compliance with the process and pathway, it is indefensible to link a resource to a set target reduction. This has the potential for a highly detrimental impact on decision making in general practice.

It is also indefensible in the eyes of the public. We risk becoming scapegoats in the run to achieve financial balance in a system based on newer models of care with little or no evidence behind them.

What is the way forward?

Increased consultation time will help relax the pressure and may take away some of the ‘soft’ referrals by allowing us to spend more quality time with the patient.

We also need resource in form of funding, workforce and time that allows us to engage in better use of skill-mix within the practices or in the federated set-ups.

We also need the guideline development bodies such as NICE to recognise the existing pressures and really talk to Whitehall before churning out gold standards of care without any resource.

Better use of technology such as shared records across the system along with easy access and advice from our secondary care colleagues is needed. Such advisory services should also be negotiated in the contracts with secondary care.

There is also need for more debate on effectiveness of some interventions as well as overdiagnosis and overtreatment.

But, there really is no alternative to an increased resource for the system and by trying to live within the means, we are colluding to developing a system which is less fit or unfit for purpose. We must tread carefully and always be mindful of whose side we are on.

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Readers' comments (8)

  • We should never ever ever give into pressure to not refer if we feel it is appropriate. There is no safety net from the CCGs/NHS when things go wrong. Just ignore all the pressure to not refer and go with what you feel is appropriate clinically. If someone disagrees with the decision to refer that's fine but then they must take over full clinical responsibility

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  • Do whats right for you. your patient and your indemnity provider.The government and its agents can go take a running jump.

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  • Yes I ignore everything and concern myself with the patient sat in front of me.

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  • I agree with Kamal Sidhu about the dangers of caving in to the demands to reduce our referrals to secondary care.
    We must not lose sight of our duty to the patient, and we must maintain our integrity as trained, experienced senior clinicians. And that means living up to our own professional and personal ethics and standards. If we lose sight of that, then our professionalism will be worthless, and we will be no better than puppets to a bad system, not worthy of the respect and trust of the patients who rely on us.
    Our permissiveness and subservience will eat at any self-respect and self-confidence we may still have as individuals, and we will lose any negotiating and service development influence that we still cling to. The beginning of the end, my friends...unless we stand up for what is right. That is the nature of the compassion that we all seek- honesty with ourselves and others, integrity, and the courage to stand up and fight for what we feel is right.

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  • More and more areas (mine included) are now subject to a Referral Management System where various noctors filter all our referrals and bounce back those deemed inappropriate. This is done to both "improve quality" and (naturally) save money to help lower CCG debt.
    As a result there is increasing chaos as patients who were expecting to see (for example) an orthopod re their possible hip replacement are bounced back to a bewildered GP told by RMS to "consider physio" or some other meaningless diversion designed to keep the patient away from expensive secondary care.
    The spiral into madness continues......

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  • We have a duty of care to the community we serve which would not be helped by bankrupting the system. Most referrals are blocked for good clinical reasons like hip pain sufferers losing weight first.

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  • Re Peter Clayton 9.46pm

    If it was just the morbidly obese being bounced you might have a point, but up & down the land hip & knee replacement requests are increasingly deemed PLCP and referrals are sent back to GPs with facile pseudo-reasons ("have you tried analgesia?"/"too young"/"too old" etc)
    I have no objection to Consultants returning what they decide are inappropriate referrals, but increasingly we have teams of various "clinicians" who have not seen the patient bouncing referrals back to experienced GPs who have. This is dangerous and just wrong.

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  • “And that’s not to deny that those pressures may lead to less safe practice than has otherwise been the case.
    Workload pressure would not be a defence against clinical negligence, barrister warnshttp://careers.bmj.com/careers/advice/Workload_pressure_would_not_be_a_defence_against_clinical_negligence%2C_barrister_warns

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