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Gateways using nurses to screen GP referrals

Exclusive GP referrals are being screened and bounced back to general practice by nurses, physiotherapists and even podiatrists employed by PCTs to staff referral management centres, a Pulse investigation reveals.

Data supplied under the Freedom of Information Act shows PCTs that operate referral management centres to reduce the number of GP referrals to secondary care are commonly using non-doctors for triage.

In February, Pulse revealed that referral management centres were rejecting as many as one GP referral in eight for services including hip and knee replacements, cataract surgery, allergy care, IVF and tonsil removal, and one GP in three had their referrals screened by a referral management centre.

Our investigation asked for details of triage at eight PCTs known to be using referral gateways. Five – NHS Bournemouth and Poole, NHS Hertfordshire, NHS Manchester, NHS Oldham and NHS Plymouth – said they used non-doctors to assess GP referrals.

NHS Manchester – which pays private provider Harmoni to run a controversial referral management centre to screen GP referrals remotely from Southampton – said it used two podiatric nurses and a non-medical prescriber with a diploma in podiatric medicine to triage GP referrals for vascular conditions.

NHS Oldham admitted more than a third of its staff screening GP referrals in opthalmology, diabetes, urology and musculoskeletal conditions – 15 out of 40 – were non-doctors.

GPs expressed concern that the use of less qualified staff could reduce the consistency of decision making and lead to errors in patient care.

Dr Andrew Mimnagh, chair of Sefton LMC, said he knew of several instances elsewhere in which ‘patients had come to harm from not being referred'.

He said: ‘Nurses assess patients according to rigid criteria and do not have the experience to make flexible decisions in the same way a doctor can. In one case, a patient was rejected for a replacement hip operation by a nurse at a referral centre despite the fact his hip was dislocating. According to the nurse's criteria, he wasn't reaching a high enough pain threshold because he already had an artificial hip that cured the pain. Nurses do not have the knowledge to know when they are out of their depth.'

Recent research has suggested GP peer review improves GPs' referral behaviour, but referral management centres do not.

Professor Helen Smith, head of public health and primary care at the Brighton and Sussex Medical School and a GP in Brighton – who conducted the study of referral management centres – said she had ‘concerns' over their use and use of non-specialists to triage referrals: ‘There could be problems if formal training and checking on the validity of decisions being made is not happening.'

Secondary care specialists also said they had concerns that under-qualified medical staff might not appropriately triage patients.

Dr Sarah Clarke, vice-president of the British Cardiovascular Society and consultant cardiologist at Papworth Hospital in Cambridge, said: ‘I'm not surprised GPs are concerned about this. Not everybody fits the rigidity of protocols.'

But PCTs defended their use. An NHS Oldham spokesperson said: ‘Nearly all GP referrals go through a referral gateway, run by local GPs. There are some areas where we've had multidisciplinary teams in place for some years. They are people with the appropriate clinical skills and experts in that specialty.'


How non-doctors are triaging referrals

• NHS Oldham: Nurses, nurse practitioners and physio-therapists triaging referrals in ophthalmology, diabetes, musculoskeletal and urology

• NHS Plymouth: Nurse specialists triaging GP referrals along with GPs and consultants

• NHS Hertfordshire: Community and diabetes nurses triaging referrals

• NHS Manchester: Podiatrists and nurses triaging vascular referrals

• NHS Bournemouth and Poole: Using nurses and nurse specialists

Source: Pulse investigation of eight gateways