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GP clinical judgement leads to 20% fewer referrals than NEWS score, finds study

The new requirement for GPs to use the national early warning score (NEWS) to decide when to refer patients to hospital could increase referrals by almost 20% when compared with using their own judgement, a study of out-of-hours services has suggested.

GPs in England will be asked for the score – which assesses the six vital signs – when calling for an ambulance, and those behind the research said they were aware of some OOH services already routinely using NEWS.

Commenting on the findings, GP leaders said the use of NEWS reduces medicine to a ‘tick-box’ exercise and could lead to the wrong course of action for patients when calling for an ambulance or referring to hospital.

They said the study showed the importance of GPs being able to use their own judgement – contradicting claims that GPs rely too heavily on ambulance services.

Researchers from the University of Birmingham, who looked at around 75,000 records from patients in the city between 2013 and 2018, found GPs in OOH services decided against referring around two-thirds who would have met the threshold under the NEWS system.

By calculating the scores retrospectively, the researchers found if all patients who met the NEWS threshold had been referred, this would have meant a 16.2% increase in referral rates – or 26,500 extra hospital attendances every year in England.

The researchers said GPs may have decided not to refer because some patients’ problems can be managed in the community.

They concluded their findings show the NEWS system ‘does not align consistently with referral decisions’.

More research is needed on the clinical impact of scoring OOH patients, to inform policy recommendations on the use of NEWS, they added.

The study, published in Emergency Medicine Journal, looked at the records of 74,914 patients who had a face-to-face OOH general practice consultation.

It found just under half of patients would have had a score of 0 and around 7% would have scored >5 , which is the point for referral to hospital due to the increased risk of an adverse event.

Of those with a score of >5, two-thirds of patients were managed in the community and not referred to hospital.

The authors said in the paper: ‘In the setting of primary care, NEWS does not align consistently with referral decisions.

‘There are likely to be a variety of other factors influencing referral decisions that are particularly relevant to this setting including limited (or no) access to patient records and investigations, a lack of alternative care pathways and poor social and healthcare support mechanisms out-of-hours.

‘At the same time, a decision not to refer could be because the patient’s problem can be managed in the community, with an appropriate safety net and follow-up advice.

‘Further research should provide evidence of the clinical impact of the introduction of early warning score-based decision making in out-of-hours general practice in order to inform recommendations on its use.’ 

Lead author and academic GP Dr Sam Finnikin told Pulse that more research was needed to understand whether it was safe for patients with a high NEWS not to be admitted to hospital – but more importantly whether the scoring system skews GPs’ judgement.

He said: ‘Proponents of NEWS will argue it is not designed to replace clinical decision making.

‘But the problem with this is that humans will automatically focus on numbers and cut-offs, especially when we are cognitively overloaded, so the routine use of NEWS  – which is being recommended – may increase referral of patients with a raised NEWS and decrease referral of patients with low NEWS. But the impact of clinical outcomes is unknown.’

He added: ‘The introduction of NEWS in primary care without understanding the impact it may have on decision making could have untoward negative consequences in terms of over- or under-admitting patients.’

Former BMA GP Committee urgent care lead and Derbyshire GP Dr Peter Holden, said: ‘To be told that the computer won’t accept your ambulance booking without a NEWS score is just not acceptable.

‘Just because it doesn’t add up, it doesn’t mean that the patient shouldn’t go in, because there are other factors that apply. For example, are they living alone? Or even a simple one – are we about to get a snowstorm?’

He added: ‘The fact is that people assume that only clinical matters determine hospital admission. It’s a classic problem that people think that diagnosis is simple and fits in boxes – it doesn’t and that’s why it takes 12 years to train a GP.’

Dr Holden also said: ‘The biggest objection is that NEWS is not validated for use in the community, so why are we using it?’

NHS England released guidance in 2019 advising GPs to use a NEWS score when requesting an ambulance, which the BMA said could be used as a ‘barrier’ to accessing emergency care.

Pulse’s investigation into ambulance services last year revealed 999 calls from GPs were taking twice as long to be responded to as calls from members of the public.

GPs claimed under-pressure ambulance services are delaying their arrival due to the mistaken belief that patients are safe if a doctor is present.