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GPs go forth

We must help risk-averse younger GPs to cut unnecessary referrals

As practices face pressure to reduce referrals, older GPs’ experience will be invaluable, writes Dr Michael Dixon

After April 2013, the number of referrals made by GPs at a practice will become a serious matter for every partner. Of course, it has always been an important matter for patients, with some people benefitting from an appropriate referral, and others suffering when a referral might have been avoided through reassurance, advice or action by their GP. 

Every practice, as a member of a CCG, and every partner will have to take on the responsibility for making the best possible use of resources. In short, the more referrals you make to secondary care, the less money there will be for primary care or for redesigning services so that they can be provided more locally. Any action that reduces inappropriate referrals and makes the referral system more cost effective will not only benefit patients and CCGs but also GP practices and partners.

My experience is that if you look at referrals made by partners in a practice, they tend to have a linear relation to the partner’s age and experience, with younger partners referring more and older partners tending to refer less. 

There are numerous reasons. Part of it is that older and more experienced partners have encountered a wider range of conditions and problems and can often deal with them without referral.

Older partners were also brought up in a tradition whereby ‘tolerating uncertainty’ was one of the recognised features of a good GP. By contrast, junior partners might view ‘tolerating uncertainty’ as ‘tolerating unnecessary risks’. 

Older partners might be less defensive in their medicine as they have less to lose from complaints and court cases than those just entering general practice. Older partners are more used to ‘making do’. 

When I started in general practice, I had to make do with access to just half a local cardiologist whereas now I can contact five or six. We recognised that specialist time was limited and rationed patient access accordingly. Old habits die hard, especially when older partners are sometimes less up to date with NICE guidelines than their younger partners. 

This does not imply that the older and lesser referrers are right and the younger and more frequent referrers are wrong. The truth, almost certainly, lies somewhere in the middle. It does mean, however, that older and more experienced partners may be able to help those younger partners who are referring substantially more than the average for general practice. 

Offering support

As older and more experienced GPs, we have a duty to support our younger peers in navigating the contradictory forces of increasingly demanding and litigious patients, endless guidelines, a cash-strapped NHS and the fundamental wish of every doctor to do their best for every patient.

An important start is for GPs to leave their doors open to junior partners. In our practice, we have a half-hour coffee break every morning where, at least in theory, we aim to discuss referrals made by the different partners that morning with a view to seeing if they are necessary. We audited this in its early days and found we had reduced referrals by almost 20%. 

When we looked at individual patient referrals within our own practice, we found that better quality of service to the patient and reducing referrals went hand in hand. This finding was similar to how reducing prescribing costs in the old days (particularly for antibiotics) often went hand in hand with better medicine.

Creating systems of peer review to enable younger and more inexperienced GPs to refer less is not simply about saving money but also about improving the quality of care and improving support and job satisfaction for younger colleagues.

By helping younger partners in this way, we will be avoiding the unpleasant alternative options. These might include each practice being given a quota of referrals, a draconian and externally imposed referral management system, reduced services with longer waits or punitive measures on GP practices that refer more than average.

And on the plus side, we will be contributing towards better care, happier and more fulfilled younger partners and the overall sustainability of the NHS. 

Dr Michael Dixon is chair of the NHS Alliance and a GP in Cullompton, Devon

Readers' comments (15)

  • I'm afraid this could easily be interpreted as very condescending to young GPs , and as you say older GPs may not be as up to date regards referral thresholds of various symptoms etc- many of which lets face it are now covered with the ocean of guidelines out there

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  • It is an irony that we are led by financial economics in medicine. We as doctros are here to provide best evidence based medicine.
    What is irritating is the fact if any thing goes wrong it is that particular doctor who is in the dock, and not CCG or Dr Dixon.
    My advice is to continue to be risk averse, it is your career on the line.Unless the goverment is willing to provide immunity to all drs not-practicing risk averse medicine!

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  • This is the reason why doctors , mainly the younger doctors , are now leaving the UK to work abroad - Canada & Australia.
    Lets face it why do we want to work in the UK when:
    1. GMC are very patient focused and put doctors under serious pressures. They are quick to suspend a doctor over a complaint. ie patient power is stronger than doctor power.
    2. restrictions in practicing because of cost issues etc
    3. the work load is high.

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    Those closer to retirement are likley to take more risks .. they have less to lose and a better pension

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  • Tom Caldwell

    So refer less but miss nothing? I have audited my 2ww referrals and those of the practice. I refer the most via this pathway but have picked up a cancer diagnosis on 45% of my 2ww referrals. I would be loathed to refer fewer as I genuinely feel this would lead to missed diagnosis.

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  • Outcome data is the 'holy grail.

    Rather difficult in interpreting outcome data though to escape the inevitable pitfall of 'lies, damned lies and statistics' eg what if patients know that Dr A will not refer them so they select either of these options:

    1. see Dr A for minor conditions or a quick opinion if Dr B not available
    11. If not happy with Dr A's opinion, or suspect have major condition then see Dr B.

    Who then is going to be the high referrer?

    Incidentally part 111 of above might be:

    111. Dr A on CCG work today. Ok better see Dr B then.

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  • It saddens me to hear the fear of litigation amongst some commentators.Take a chill pill guys! If you have a good relationship with your patient and adequate safety-netting within consultations you leave the door open for the patient to return if your course of action doesnt work out for him or her. Dont forget that intrapractice referrals are a good way of accessing expertise eg parners with a special interest in dermatology,cardiology gynaecology or musculoskeletal medicine and reducing referrals to secondary care.

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  • Harry Longman

    Interesting anecdote about older doctors referring less. But we need evidence on a larger scale to authenticate this. If true, it could have implications in all kinds of areas. Anyone done a study already? Or could set one up?

    What we do know is the link between better continuity and lower referrals - Prof Richard Baker's paper Leicester University study 2012 JPH. Let the GP manage the patient continuously, and some referrals are avoided.

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  • OMG! The curse of the 'inappropriate referral' is back just after Sir Mike Richards said it's safe and wise to refer all patients with symptoms of cancer.

    So now only patients who fit the cancer 'stereotypes' will get referred, not all the patients who persistently display cancer symptoms.

    We'll deal with these losers in-house and hope for the best. If their relatives do sue we'll have retired by then.

    Hang on a minute! What is an 'appropriate referral'?

    What does the DH consider

    a) the appropriate % of all cancers not diagnosed under the 2ww?
    b) the appropriate % for a single GP's hit-rate under the 2ww?

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  • It shouldn't be about the referral. Surely to rule out or confirm diagnosis is a must. If however the patient is seen in secondary care and can then be managed in primary care the referral isn't wasted. It has confirmed diagnosis and the management plan for the patient.

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