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Debate: Should we increase patients’ ability to self-refer to secondary care?

Debate: Should we increase patients’ ability to self-refer to secondary care?

Two GPs debate Labour’s recent plans to reconsider GPs’ gatekeeper role


Self-referral would save time and money

Professor Dame Clare Gerada

During an extraordinarily busy period last year, I went through thousands of digital consultations to triage them according to the level of urgency and the clinician or service that would be right for the patient. It was exhausting, but I realised how we underestimate our patients and their ability to know what they need.

I was also frustrated that, if only patients could have direct access to the services they needed without me as a very expensive secretary, I could have spent longer with those who needed me. Why couldn’t patients use the referral templates I use?

Looking at the literature, I was surprised how little evidence there is for the gatekeeper, which has been enshrined in NHS clinical practice for about a century. Even in randomised trials, there is not much evidence about whether going via the GP or direct to a specialist would lead to more referrals, whether patients would do better or worse with no gate, nor how wide an effective gate should be.

I’m not undermining the role of the GP as a coordinator or patient navigator. This is about whether we can capitalise on what we learned during the pandemic, which is that patients can take more control of their health. If we could empower patients and had clear referral guidelines, why should they not be able to self-refer for something that we would on their behalf?

Why not have direct access to chest X-rays? If a patient has had a cough for more than six weeks, I would refer them for a chest X-ray. Rather than dismissing the idea of self-referrals, we need to have a discussion with both our colleagues and patients to see where we can open the gate a little more.

Evidence is limited, but where it exists it shows that direct access reduces waiting times, improves outcomes (especially for cancer) and uses less in health costs. I remember a time when a patient who needed a termination of pregnancy had to be referred by me, often resulting in a five-week delay. Now, we trust them to do this themselves. The same goes for referrals for counselling, eye checks, hearing checks and physiotherapy. And once we get proper digital triage and AI, we can do more.

   We have to look at this as an opportunity. Whether we like it or not, it’s probably going to happen anyway. We just have to make sure it happens safely where it can.

Professor Dame Clare Gerada is a London-based GP partner and president of the RCGP. She writes in
a personal capacity


Self-referral would be a costly mistake

Dr Martin Brunet

The Labour party has declared that the NHS is in peril and may not survive. Few would take issue with its diagnosis or prognosis, but the suggested treatment plan? It makes as much sense as telling a patient with acute coronary syndrome to go on a brisk run around the hospital.

Labour’s prescription for self-referral to specialists, bypassing the guiding hand of a GP in deciding when a referral will be helpful and which specialist to consider, may appeal to voters. But quite how this is supposed to resuscitate the NHS is – to coin a phrase – both murky and opaque.

It is easy to imagine there would be efficiencies with self-referral; if the patient can go direct to the specialist, that’s one fewer appointment for the GP. What’s not to like? Well, the problem with this simplistic view is how it fails to understand the different roles played by primary and secondary care and, crucially, how their distinctly different approach is dependent on the different cohort of patient seen in each setting.

No one has explained this dichotomy of purpose better than the late academic and GP Dr Marshall Marinker. He described how primary care, in seeing undifferentiated patients, first marginalises danger. The GP considers serious causes such as cardiac chest pain or cancer, ruling them out or acting on them without delay. Once danger has been reduced in this way, a degree of uncertainty can be tolerated, and the GP considers probability. What is the most likely cause? What is most likely to help?

Secondary care, on the other hand, sees filtered patients. Another professional, working in primary care or the emergency department, has determined that the patient needs to be referred on. Such patients are more likely to have serious pathology and so the secondary care physician needs to marginalise error, to make sure that serious pathology does not go undetected. As such they consider not just what is likely, but what is possible, aiming to reduce uncertainty by testing out all these possibilities. This approach justifies a far higher use of resources, as intensive investigations are required to achieve these aims.

It doesn’t take a health economist to calculate that if even a small proportion of the unfiltered patients in primary care took themselves directly to the door of our secondary care colleagues, the financial woes of the NHS would rapidly escalate, and Labour’s ‘cure’ would hasten our institution’s sorry journey to the mortuary.

Dr Martin Brunet is a GP and medical trainer in Guildford, Surrey



Please note, only GPs are permitted to add comments to articles

John Evans 28 January, 2023 10:17 am

It is bizarre that number 2 in the most commented articles on Pulse is an article about 2/3 of GPs’ experience that Advice and Guidance blocks access to care.

Ie NHS needs to demand manage due to demand exceeding capacity.
Yet somehow the NHS will somehow accept direct referrals from patients?

Anticipate that the system will either incorporate some form of non-thinking / flow chart gate keeping. It is not hard to imagine the unintended consequences of false messaging or false reassurance that patients might derive.

Waiting times will extend and even a small increase in worried well accessing care (“because you can never be too careful”) will displace or delay those with serious underlying medical conditions.

It will not free up time as GPs will end up discussing the issues after the fact which will be disadvantaged as we will be entering the care process later in the game and potentially without all of the information.

Andrea Barrow 28 January, 2023 11:29 am

Fundamentally the problem is lack of capacity and it doesn’t matter how many referrals are done or by whom they are done, there is no capacity to manage them.

David Banner 28 January, 2023 12:33 pm

Surely anybody who thinks about this proposal for more than 5 seconds would conclude that it would be a car crash.
Yes, in a fantasy ideal world it’s a great idea, but in the grim reality of the bleak midwinter of 2023’s NHS it’s laughably naive to think this would result in anything other than even more chaos and carnage.
Wake up, dreamers, it’s time to face the real world, and it ain’t pretty.

Christopher Jones 28 January, 2023 9:11 pm

Out of interest, has Dame CG ever said anything worth hearing? It just seems that every time she opens her mouth or puts pen to paper, she is able to find yet another way to undermine the profession.

Anonymous 29 January, 2023 6:34 am

Self refer to:
– dermatology by sending them a pic.
– ophthalmology after having seen an optician with their recommendations
– psychiatry using current triage arrangements
– cancer hubs with suspected cancer (alongside GP referrals)
– physiotherapy and orthopaedics having seen PT first
– paeds for children between 5 and 16 with triage outcome and advice sent to GP where not appropriate to be seen.


Darren Tymens 29 January, 2023 5:56 pm

‘I’m not undermining the role of the GP as a coordinator or patient navigator.’
* Yes, yes, you are
‘She writes in a personal capacity’
* No, because this appears to be the opinion of the Chair of the RCGP (Opinions such as these voiced in public and in front of politicians by CG and HSL are why I left the RCGP)
Rather than having loads of unecessary consultations and investigations organised by people who aren’t medically trained and therefore unlikely to know what they are doing, why don’t we just train enough generalist doctors who can help patients navigate quickly, safely and efficicently through the system using the minimum amount of scarce resource. We could even site them in buildings in the communities they serve, away from the temptation to admit and over-investigate.
We could call them ‘family doctors’ or ‘generalist practitioners’ or something like that.

Centreground Centreground 30 January, 2023 6:25 pm

Just because certain GPs think we want to constantly hear their views does not mean this is the case – if we had a change of GPs giving opinions we may have a change in the dire performance of General Practice over the past 10 to 20 years and perhaps in a more positive direction.
In my decades in General Practice the biggest waste of money has been having to pay the RCGP which I consider to one of the country’s most ineffective organisations

Turn out The Lights 31 January, 2023 1:56 pm

What would be funny is advice and guidance being sent back to the self referer. Where would they go then eh!

Malcolm Kendrick 31 January, 2023 4:38 pm

I was doing telephone triage one happy day. A male patietns in his forties phone up. His wife had noticed a mole on his back had goe bigger, changed shape, to become irregular, and was now thickerr than it had been. I referred him, over the phone, to dermatology 2WW. it was a melanoma, and was removed. I believed there was no point in seeing him because, with that history, there was no way I was not going to refer him.

All was well?

I got a complaint from the patient that I had not ‘bothered’ to see him face to face.

Douglas Callow 3 February, 2023 11:45 am

Malcolm Kendrick Priceless
Sadly that’s the GB we live in now
politicians happy to dabble in the dark arts of Polarisation Post truth Populism
Knackered economy
no money due to Colossal debt (propping up the housing market and covid) Massive own goal with Brexit
UK High inflation a mix of profiteering and supply side demand

Rogue 1 3 February, 2023 11:52 am

Unfortunately there is a precedent. The French went down this path years ago, but it led to so many hospital appointments and people in the wrong clinic, they went back to the system of referral from primary care.