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The [insert specialty here] referrals crisis

The [insert specialty here] referrals crisis

Our cover feature makes for grim reading. It’s of no great surprise that there is a mental health crisis, or that the pandemic has exacerbated it for all sorts of reasons.

But it is shocking how much of this is falling on GPs, who often have to work beyond their competence to monitor patients with eating disorders, perform weekly ECGs, initiate antidepressants in children and so on. 

There was a reason we chose to focus on mental health. It is where the lack of access is most obvious and the pandemic has increased the numbers in need of support. Most of all, though, it’s because GPs’ own mental health is suffering.  

It should be the case that a GP does not feel the weight of responsibility for a patient once they judge specialist care is necessary. But unfortunately, that’s not the world we live in. What makes GPs great is that they will do all they can to help vulnerable patients shut out by secondary care. But when this proves beyond them, the GPs suffer ‘moral injury’ – a phrase that arose all too frequently in our feature, referring to the damage to someone who is unable to prevent acts that transgress their values. In other words, when GPs feel helpless to support patients with mental health problems, it exacerbates their own. 

Sadly, this doesn’t just apply to patients with mental health problems. The cover feature could have been written about any number of specialties, and the same issues around moral injury can occur for GPs whose patients are unable to access pain clinics, for example. 

To highlight the problems of secondary care access, it is now official policy in England for GPs to take on responsibility for many patients who would normally be seen by specialists. The increasing use of advice and guidance (A&G) seems to have bypassed much of the media and the public, but it represents a fundamental – and worrying – change. The uncertainty around who holds liability if anything goes wrong underlines what a shift this is – and the potential threat to patient safety. 

I understand why NHS England wants to promote A&G, as secondary care is under unprecedented stress. But general practice is also under unprecedented stress. 

I’ve argued before that warnings from the profession each winter (and, increasingly, spring, summer and autumn) that the NHS ‘is on the verge of collapse’ are unhelpful. There will be no collapse as such. What happens is GPs take on more work they are not trained for, secondary care gets steadily worse, mortality rates rise and those who can increasingly use private healthcare. In such a stressful environment, primary and secondary care point fingers at one another. 

Now, I said at the start of the column that the cover feature was grim, and I accept this editorial is no lighter. But I’ll leave you with a more positive thought. GPs and specialists are on the same side. Doctors in general are trusted by the public and they are stronger when speaking with a single voice. The profession must not turn on itself. No specialist wants A&G taking the place of hospital appointments, or GPs acting beyond their competence. Secondary care doctors should avoid the trap of blaming poor GP access for A&E pressure (as should paramedics). Equally, GPs must not blame specialists for a lack of referrals. 

As soon as we’re all pointing our fingers where they should be pointed – at a Government whose austerity has damaged the NHS and all public services – the more likely it is that this situation will start to change.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at


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Vinci Ho 11 May, 2022 6:15 pm

Several points :
(1) Advice and guidance has become a ‘compromise of a compromise’ if that makes sense . The system is dangerously short of GPs, specialists and nurses at the frontline. But GPs are always the first contact for patients with problems of different severity . In cases where the severity is genuine and beyond the remit of generalists i.e. GPs , instantaneous access to specialists is vital . Very often , many patients with serious underlying diagnoses had to present themselves to A/E because they could not wait any longer . The GP would have done everything to expedite the appointment to see a specialist. But we all know the potential answer that will be given to these patients ( even when they were already seen in A/E). How do you think the patient and GP would feel at that moment , Mr Health Secretary ?
Of course , if they are already so seriously ill with all the obvious textbook signs , they will be immediately admitted . The word standing out here , however , is ‘late’ .
Then the question begging here is ‘ Is this so called safe service ,Mr Health Secretary?’
(2) Between a GP and specialist , who is in the worse predicament under current system ? One can have all kinds of arguments from both opposite ends . The reality is a serious shortage of experienced doctors (and all NHS frontline staff) because they are leaving or reducing commitment substantially . Impossible workload is laid upon them due to unrealistic , insensible and ignorant political decisions made at the top of the system .
(3)The word ‘reform’ is an easy clique for politicians to answer to their voters . The so called investment of resources are not to replenish what is already seriously lacking before the pandemic but to tell the public everything will be ‘good’ soon with these ‘new’ investment . And I always insist resources mean money , expertise/experiences, manpower/workforce and TIME. They are one for all , all for one .
Yes , the country needs a post-Coivid recovery as soon as possible . But is the government and its propaganda media realistic ,honest and humble enough to reveal the truth that recovery can only be achieved stage by stage with time? The most valuable asset of NHS is all the frontline staff ( doctors, nurses , paramedics, list goes on) . How are they being treated right now ? That is a question not just for politicians but all policy makers , stakeholders , academics etc living currently at the top of the ivory tower .

Simon Price 11 May, 2022 6:52 pm

There is no fundamental difference between GP’s and hospital specialists. Most GP’s could provide most specialist care with suitable time and training. What GP’s cannot do is be GP’s and specialists. Something has to give. So a GP specialist cannot provide GP services and specialist services at the same time. Could someone let Government know please!

Vinci Ho 13 May, 2022 12:15 pm

I had just read the article currently most commented on this platform ‘ Two thirds of GPs providing specialist mental health support beyond their competence’ and left my comment under that
But I think it is also appropriate to copy and paste my comment under the article as well 👇

(1) It is not just mental health. This survey captured exactly the ideology of Jaimie’s editorial right now : ‘’The [insert specialty here] referrals crisis’’ ( I had laid down my comment under the article)
We , NHS GPs, always have the code ,conscience and capability to travel the furthest distance to help our patients , especially those with multiple complex problems .
But ( always a but), competence is another matter and will become a serious problem (occasionally disaster) if GPs are forced to go beyond their boundary of competence because they really want to save their patients despite a totally broken system . (thanks to our politicians , stakeholders , certain ignorant and/or devious media and even the a academic up the ivory tower ) .
One of the main principles laid down by GMC about going beyond a clinician’s competence is crystal clear .
(2)If you are a Star Wars fan , you would remember why the Jedi knights were extinguished , exterminated completely( leaving one last one) not because they were ‘bad’ and did the wrong things . They were destroyed exactly by duplicitous , power-thirst political enemies obsessed with the dark side .
(3) Coming back to our reality , I accept the argument , ‘’There is no fundamental difference between GP’s and hospital specialists. Most GP’s could provide most specialist care with suitable time and training.’’ And there are indeed many good GP with extended interests with ample knowledge in different specialties.
I , myself , had a diploma and master degree (Cardiff University) in practical dermatology and used two dermoscopy machines everyday .
But I will NEVER call myself a specialist . I remain as a generalist because of both the ethos and telos of a generalist . Generalists are there to practise the ‘art of medicine’ not just the science .
However , when it comes to safety , the art is exactly about getting special help sooner rather than later when things appear to be more ‘complicated’ . This system is currently failing us(all frontline colleagues ) and therefore our beloved patients .