Columnist Dr David Turner says secondary care should rethink its approach of telling GPs what patients do not have wrong with them as it leaves them searching for answers
Have you noticed how secondary care seems to increasingly tell us what patients do not have, rather than what they do have? I reflected on this recently while reading letters sent to me from secondary care.
The gastroenterology team frequently ends colonoscopy reports with ‘no signs of bowel cancer’, and nothing more. Fine, we needed that excluded. But the patient still has undiagnosed gastrointestinal symptoms, which are going to bring them back to me and potentially lead me to refer them back to secondary care. Why not arrange to see the patient and discuss the next steps? We will usually have done as much as we can in primary care already.
The out-of-hours NHS 111 reports are no better. The list of what the patient does not have usually runs to a whole page. It seems everything the patient has not experienced – from a postpartum haemorrhage to an ostrich bite in rural Zimbabwe – is listed, with what is actually their presenting complaint buried in the text as a one liner. Or more often than not, after a comprehensive list of negatives, the phrase ‘advised to see their own GP within four hours’ is printed at the bottom of the page.
Outpatient referrals often feel like headbutting a brick wall (not a RAAC one, though). Patients referred to ENT with prolonged vertigo tend to have an MRI to rule out inner ear tumours and are then sent back to the GP. Super! So they do a scan to rule out a rare cause, then dump the patient back on primary care to vent their spleens about nobody actually making a diagnosis or doing anything about their symptoms.
The NHS has always predominantly been an ‘illness’ rather than a ‘wellness’ service, but recently it seems to be becoming a ‘rule-out-cancer-and-dump-everything-else-back-on-the-GP service’. Now, this is not necessarily a problem. In fact, if we were given sufficient time and resources, we could probably deal with a lot of the non-cancer-but-nonetheless-significant symptoms better in the community.
For instance, we could employ more counsellors to treat our IBS patients with CBT and biofeedback, as well as more physiotherapists specifically to treat labyrinthine disorders. Diverting funds from NHS 111 to primary care might mean we could up the pay rates for out-of-hours work and perhaps encourage more doctors to work in primary care. At least that way, patients could talk to an individual who has spent a decade training in medicine, rather than a call-centre operative following a flow chart.
Fanciful suggestions? Maybe, but I am certain I do not have a mono-delusional disorder.
Dr David Turner is a GP in Hertfordshire. Read more of his blogs here
agree 100% its a complete joke 2ww GI service is a cancer exclusion service Little or no effort to answer a clinical question Leaves patients underwhelmed and GPs exasperated I may as well send straight to test and review and keep the tariff
Equally unhelpful is a+g queries where patient needs appointment or something doing and they pass it straight back
Very poor VFM for health economy and real drain on my resources
I recall my old gastroenterology boss writing to a GP saying, “I would counsel against the practice of exclusion medicine,” after the GP had referred asking for gastric cancer to be excluded in a patient with upper GI symptoms. How times have changed.
Well, it seems we are in the middle of a pandemic, so only able to justify excluding very serious cancerous disease with the risk of infection; anything else is not urgent enough to justify risky infection exposure, and can wait until the pandemic is controlled.
Which in fact I fully agree with – the Pandemic can be controlled, if the population as a WHOLE including the rich and powerful, would support the vulnerable and less well off to isolate whilst we close international travel and mass spreader events and eradicate the virus, and then all the NHS staff and patients could return to a really normal life.
Unfortunately, it would require significant equalisation of financial resources across the class divides, which a small minority (mostly MPs and rich business owners with vast income streams they wish to continue in full flow) are not willing to do.
So we have to put up with ’emergency only’ treatment and seige conditions for longer, to please the selfish rich MPs. How long till the population decides that this is just not good enough?
Agree 100%.
Local urology service (AQP) frequently gives no diagnosis, explanation or management that I can see.
They seem to interpret their function as confirming that cystoscopy and ultrasound were normal, then discharging with not so much as a comment on what might actually be ailing the patient. Their waiting times however are years shorter than the DGH, and I suspect no appointments for DGH even appear as bookable any longer on choose & book/ERS.
Nowhere do my referrals ask “Can you please just ensure that regardless of relevance to HPC, the procedures/items you can bill the NHS for are undertaken, confirmed to be ‘normal’, while making sure to avoid any engagement with managing the presenting issue?”.
I had thought it would be patronising to ask on an initial referral: “Please might you, as the specialist in this area, apply some of that expertise in assessing, diagnosing, educating, proposing and initiating management, above (rather than below) that which we have already pursued in Primary Care, and if after all that if its not too much trouble, document this for benefit of patient and me.” but since these are inevitably my sentiments on receiving the poorly constructed summary notes (not even clinic letter), I may have to think again.
P.S. While I am always one to give the benefit of doubt, patients invariably confirm they were told no more about their issue than the summary states, and often even less.
worst case of this I ever saw – patient referred to gastro with severe weight loss, altered bowel habit, massive upper abdominal distension and anorexia; gastroscopy carried out, patient discharged with “no abnormality found”, No follow up recommended, goodbye.
My favourite endoscopy discharge letter as well as saying endoscopy normal , and paragraphs about leg swelling and dvt , failed to mention that the patient died during the procedure….