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

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

YES

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

NO

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