Bounced, triaged, ignored – the National Inhumanity Service
Following a nine-month wait for a response to a referral he made for a patient, Copperfield asks if the NHS has lost its capacity for empathy
So now I know how patients feel.
For some time you must have noticed the arms-length way in which secondary care and community services ‘manage’ our referrals. When, by some fluke, they’re not bounced back because they don’t fulfil criteria or because a box has been ticked in the wrong font, the outcome is likely to be the same. A standard letter to the patient, unsigned and with no contact number, explaining that their problem has been triaged, that they do not need to be seen and that they would best be served by ‘clicking on the links below for helpful information’.
In just the last week, I’ve seen three examples of this, from musculoskeletal (who knew that physios could be recycled as self-help leaflets?), child mental health (which I’m beginning to doubt actually exists any more as a specialty) and paediatric dietetics (in which the ‘offer’ was for the mum to click a link, from a list, ‘the issue which most closely resembles your child’s problem’).
Well, now I’ve had a taste of this myself. Specifically, a response to a referral made nine months ago for an elderly lady with recurrent cystitis, resistant to all the usual measures. It consisted of a cut and paste letter pointing me towards some guidance, all of which I should follow, and feel free to only then refer back, yada yada.
So it took them about a year to simply tell me to f**k off. And we can look forward to more of this, now, with mandated A&G.
What a dismal thing the NHS has become. Remember its core values articulated in the NHS constitution, such as compassion, respect and dignity, working together and a commitment to quality? No, me neither. It’s felt for some time that there must be target-driven incentives for quantity over quality, evading all forms of interaction and treating patients like shit.
Sadly, general practice isn’t immune to this. While we have at least, defaulted back to F2F, unlike secondary care, we are increasingly using contact-avoidance measures – such as virtual receptionists, which transforms the human relationship patients previously had with a practice to the status of the one you’d have with the average bot-run call centre.
What we’re left with is a National Inhumanity Service. Worried that doctors will be taken over by AI? I wonder if anyone would even notice the difference.
Dr Tony Copperfield is a GP in Essex
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READERS' COMMENTS [12]
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GPs should write on every referral
‘ this patient is exercising patient choice legislation and their legal right to see a specialist and expects this to be honoured. If the referral is rejected you are advised to think about the potential medico-legal consequences of this decision ’
then paste in this guidance on the letter
https://www.landmarkchambers.co.uk/web-content/uploads/PDFs-documents-and-other-resources/Resources/guide-to-nhs-law-a-guide-to-the-law-on-patient-choice.pdf
So, yes the new mandated A&G is going *against* patient choice legal rights as they currently exist? Can someone confirm if that is correct?
yup the patient remains a burden to the NHS and they are just not interested in seeing anyone
Or as Crusher Nutjob says – the National Hellf Service…
Of course I can’t disagree Tony but… what choice is there??
Medicine is the victim of its own success. Constant “improvements” in medical processes consist of an ever greater degree of intervention and monitoring. I saw a patient this week – fitness enthusiast in his 40s who runs 50k a week – who consulted because he had been warned his hba1c of 40 was “approaching prediabetes”. He wanted an insulin resistance test.
But even setting aside extreme examples like this, every guideline ever made says more intervention is needed, more monitoring is needed, more consultation time should be given.
There is no level of funding which can keep up with this growth in medicalisation.
All the services feel the pressure, and all any service can do is try to pass the parcel.
Unfortunately GPs are usually the ones holding it when the music stops.
Fairly soon there will be media outrage stories of bounced patients suffering and/or dying.
So who will be blamed? You guessed right!
It’s important to prep patients you refer that they may be bounced, through no fault of the GP, and that they must direct their ire and complaints to the hospital.
Patients need to know that their health is being sacrificed at the altar of Waiting List Targets BY SECONDARY CARE, not by us.
Increasingly snotty letters should be fired back to the hospital pointing out they hold medicolegal responsibility.
This will totally destroy the GP/Consultant relationship, but, hey, we didn’t start this war, and we can’t allow the Bouncers to get away with it.
As DB above says, I think this is a rare “ball in our court” opportunity to show the patients we’re in the same boat (all be it, sailing down s*** creek)
I know this doesn’t address the woeful state of the NHS, but this unfortunate woman may benefit from: daily D: Mannose, urethral application of oestrogen cream, triple voiding technique when passing urine, cotton underwear changed two or three times a day, using a bidet after a bowel movement (over the toilet basin types are of reasonable cost), and drinking fluids over night. Avoidance of penetrative sexual intercourse or never going to sleep afterwards without drinking a pint of fluid may also help.
Roy Lilley eloquently summarises this
In the good old days when…
… GPs would see you in their own homes and their dining room was the waiting room…
… most would have a little black book; the names and contact details of the consultants that worked in the hospital.
If you turned up with something a bit iffy, they’d give their mate a ring, who’d either say; prescribe this or that, or send them to me and I’ll have a look.
We’ve come a long way since then and I’m not sure the time and distance calculation is an equation for the better.
Anyway…
… the latest wheeze is that one in four GP referrals will be channelled through advice and guidance (A&G) with a hospital consultant. It sounds tidy.
A quick specialist steer, fewer unnecessary outpatient appointments, smoother flow, but…
… look a little closer. You’ll see something else.
A policy that risks creating more process, more delay and more ambiguity…
… while achieving very little of substance.
The central flaw is not clinical. It is behavioural.
If you ask GPs to use A&G in a fixed proportion of cases, while leaving them holding the legal risk, they will respond rationally. They will use A&G not to avoid referrals but to protect themselves on the way to making one.
Faced with uncertainty, a GP has two pressures.
The system says… reduce referrals.
The law… and…
Professional instinct says; don’t miss anything serious.
When those collide, safety wins. It always does.
So what happens?
The GP submits A&G requests on a cases they already suspect will need referral. The consultant replies… please refer. The referral goes ahead, and…
… now there is a documented exchange, a second opinion on record, a visible audit trail. The GP has done the right thing, and has the paperwork to prove it.
From the centre, that looks like success. Another A&G case completed. From the GP’s point of view, it’s prudent practice.
From the patient’s perspective, it is an extra step, and usually an extra wait.
Nothing has been saved. The referral still happens.
This is Goodhart’s Law in action;
‘… when a measure becomes a target, it stops being a good measure.’
A&G ceases to be a clinical tool and becomes an administrative ritual. The system starts marking its own homework.
Worse, this behaviour will compound.
Consultants will quickly recognise the pattern. Cases that clearly need referral arrive as A&G queries. The result…
… two touches instead of one. GP to consultant (A&G), then GP to consultant again (referral), then outpatient appointment.
More friction, not less.
Volumes will rise, and A&G clogs-up. Turnaround times lengthen. The very cases where advice might genuinely avoid referral get delayed behind defensive traffic.
The policy begins to consume its own capacity.
Underpinning all of this, a fundamental problem… responsibility.
A&G blurs the lines.
The consultant advises but does not assume care.
The GP acts on another clinician’s input. If something goes wrong; delay, deterioration, missed diagnosis…who is accountable?
In practice, it will be the GP. The patient remains on their list; the duty of care has not shifted.
This is displaced risk, and…
… where risk sits, behaviour follows.
If GPs feel exposed, they’ll practise defensively…
… that means more checks, more steps, more documentation. In other words, the exact opposite of the streamlined pathway policymakers imagine.
There is also the issue of delay. A&G inserts an extra stage into the pathway;
request,
response,
possible further tests,
then referral.
Each step adds time.
In medico-legal terms, delay is dangerous territory. Failure to refer is not an abstract concept; it’s one of the most common routes to litigation.
Will this reduce referrals? If you insert a gate, fewer people pass through it immediately, but…
… demand doesn’t disappear. It recirculates.
Patients come back. Symptoms persist. Many will be referred, eventually, and potentially sicker.
This is not demand management. It’s queue management…
… an attempt to reconcile two irreconcilable pressures;
rising demand and
finite capacity.
A&G is being asked to bridge that gap. It cannot, because…
… in the end, this isn’t advice and guidance at all…
… it is referral management by another name. Adding a step, shifting the risk, and creating the illusion of control…
… while the underlying problem remains untouched.
This whole circus of a referral system is why I have just taken early retirement.
We are being asked to do our job without the backup of secondary care.
Most of the time, the referrals don’t even get under a consultant’s nose.
I sent a neurology referral with a normally documented examination (e.g., power 4/5, etc.), and the response after 3 months was from a nurse who complained she couldn’t understand what I had written and asked me to rewrite it without using “jargon”!!!!
Circus is the only way this referral management system can be described. I hope public can access this and are aware of what we think, and feel about it
18 referrals rejected so far. A few are mine-others are from salaried doctors, out of hours and locums. This is generating further work load and patient misery.
The same consultants happily see the same patients privately. It is a real mess.