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Independents' Day

We're so enthused by peer reviews, we've started already

Dr Richard Cook 

No doubt you have been made aware of the latest NHS England back-of-a-postcard missive about peer review? No? Check your junk mail box then.

New guidance has been issued, seemingly without recourse to a sat nav – but that is to be expected from the masters of suck it and see, let’s give it a whirl, despite the lack of evidence.

‘Good practice would be for GPs to review each other’s referrals at least once a week to ensure that all options have been considered blah blah blah…’

The new directive was revealed by our ferreting journalists at Pulse.  

We were so enthused by the potential, as yet unseen, benefits of this process that we threw caution to the wind and instigated it in our practice without even waiting for the ‘significant additional funding’ to arrive.

My wife was slightly alarmed when, on the back of this, I bought up half a million Virgin shares, but I reassured her, the cheque is in the post and Stephen Hawking is never wrong.

Conversations with GP colleagues from the CCG have been interesting since we embarked on the initiative.

‘Bob – I see you referred Mr First Fit for a neurology opinion. Any particular reason for this? Did you consider other options? There is a sale on at Sports Direct and we might be able to tide him over with a new cycling helmet and mouthguard?’

‘Nah – tried that but couldn’t get the blue one and the CCG only have a contract for mouthguards if you are over 55 and have a cat named Trump.’

‘Ok – what about Mrs Loud TV, you’ve referred her to audiology. What’s that all about?

‘Well – she can’t hear.’

‘Are you sure?’


‘Don’t be stupid Bob – this is a serious exercise with benefits to patients and GPs, AND it could reduce referrals by up to 30%! How do you know she can’t hear – where’s the evidence?

‘Oh, you want evidence now. Is that a new thing that NHS England has recently discovered?’

‘OK – what about Ms Knobbly Knees? You’ve referred her again to the orthopaedic team? What’s the problem?’

‘Well I’ve referred her twice before. The first time they said they hadn’t received the letter, and the second time they sent her an appointment letter the day after her appointment. Obviously we have already spent a week of office time chasing this up so it’s great that we have this opportunity to wallow in self pity each week over the state of our secondary care system.’

‘Don’t start getting gnarly Bob.’

‘OK – got to dash anyway, patients to see and all that. Same time next week? By the way, if NHS England were serious about helping GPs and patients can I make a suggestion? Try peer reviewing all hospital discharges and outpatient appointments. Simple things like did a letter arrive within a year of the event, has the patient got their medication, do they know what the follow up arrangements are, are the community services aware, did they bounce straight back in to hospital etc etc.

‘This would free up GP time, and make patient care smoother and safer – there’s probably even some evidence for it if you look hard enough.’

Dr Richard Cook is a GP partner in Hurstpierpoint, West Sussex. You can follow him on Twitter @drmoderate


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Readers' comments (4)

  • Amen, brother.

    I suggested our newly crowned most powerful list mull the thrust of your article till it really really hurts.

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  • Healthy Cynic

    I think that this new edict from NHSE gives us, the profession, the perfect opportunity to say at last 'No. We're not doing that. And you can't make us because it's complete hogwash. What are you going to do about it?'

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  • Cobblers

    The kicker in all of this tosh is the bit in the guidance that states that the referring GP retains clinical responsibility at all times.

    So in others words if this committee of 'peers' refuses your referral and if sh1t happens, as it does, then it will be your gonads being roasted on an open fire by my learned friends.

    Seriously?? Who thought this rubbish up?

    I suspect I will be ignoring peer review in whatever guise it comes out in.

    And/Or including the GMC numbers of the peer committee and advising said GMC that those peers cannot absolve themselves of responsibility for poor decisions.

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  • At risk of courting abuse here, there are some benefits to limited peer review - which those of us in properly functioning practices have been doing for years.

    Huge benefits in being able to say to your colleagues "look, you know mrs so and so, she's got this and I'm not sure if it's right to refer her now or to do something else first, what do you think?"

    On an informal basis it is enormously helpful and we do it all the time.

    But there is also an argument to improve referral letters to make priority triage easier for the clinicians at the other end (who are as stretched as we are, don't forget). A letter saying "please see and treat" is useless, and may conceal a very high priority case or a very low priority case.

    There is guidance being worked on to help us write better referral letters, just to remind people to include basic stuff like what has already been tried (and what dose and for how long), but also the most critical part of the referral letter is frequently missed - the expectation of the GP. Is this a referral for advice, ongoing management, treatment or reassurance.

    But a formalised and compulsory peer review committee like this is unlikely to be helpful - more likely to create extra work for all involved, introduce delays and increase risks to patients. Where is the evidence for this?

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