Dr Katie Musgrave on how long waiting lists are impacting patients
Your cruise ship has hit an iceberg, there is a gaping hole in the hull and water is flooding in. Not too far from land, but knowing the ship is sinking, the crew now have a choice: round up the elderly, pregnant women and children, and offer them lifeboats; or leave the passengers to fight it out in a mad scramble.
This week, I wanted to write about the impact of long waiting lists on our patients. Outpatient appointments that might have come through in months are increasingly taking years, and the millions of people enduring these waits are predicted to rise until 2024.
Patients with severe, but often treatable, conditions are being left in limbo – knowing that something needs to be done, but frequently powerless to improve their situation.
It has occurred to me that while we blithely refer patients into the system, GPs are not contributing as much to the triaging as we could right now.
Take those occasions where you see a patient, you feel quite confident there is nothing serious amiss, but they are simply determined to be referred. Nothing, neither hell or high water, will stand in their way.
‘We could try another cream,’ you suggest. ‘Why don’t we take some swabs and see?’ you muster. Or ‘I really think some talking therapy might help.’
I don’t believe I am the only GP who finds that, at times, I am referring patients because they simply won’t accept any other option. Yet on other occasions, I refer patients with very serious clinical concerns.
Does this lady have motor neurone disease? Something about this child seems not right – I am worried. Into the melting pot they go. Waiting years and years.
With secondary care waits now extending far into the future, our referrals should surely no longer just be viewed as routine versus urgent – isn’t there a strong case for more differentiation from the GP? I would argue that sending a referral as a 2ww, urgent, routine (with significant clinical concern), or routine (with minor clinical concern), would be more helpful in ensuring the most unwell get seen.
Some will say, ‘But it’s not our remit to decide. Who are we to judge?’ But, of course, it is our remit. We literally decide every day who should be referred for a secondary care opinion, and having seen the patients (and hopefully knowing them), we are in the strongest position to determine who needs to be seen as a priority.
From an ethical standpoint, alongside our responsibility to advocate for our patients, we have a wider moral duty to ensure that limited resources are used appropriately to create a just system and practice non-maleficence.
In an ideal world (in the present climate), every GP would think very carefully before sending a non-urgent secondary care referral. They would carefully examine the patient and likely try a range of treatments or investigations first. But with falling rates of continuity, and rising pressure on our service, this is unlikely to consistently happen.
Rates of secondary care referrals are bound to go up over time, and our most unwell patients will be lost amongst less significant problems. Of course we should be tackling capacity issues in general practice as a priority, but mitigating steps in the meantime could also help.
With waits for adult autism assessments now stretching to five years in my area, and 570,000 women nationally waiting for a gynaecology outpatient appointment (an increase of 60% compared to pre-pandemic), if we have more significant clinical concerns, we really need to find a way of prioritising those most in need.
The NHS ship is taking on water. We can cover our eyes and pretend all is well, or we can try to do our utmost to protect our sickest patients. I think it is time we conceded that some of our referrals could be seen as a lower priority.
This is a conversation we could gently have with patients while offering other options or treatments. It might feel uncomfortable, and we will undoubtedly be the subject of more frustration.
But no one can deny that lives are at stake.
Dr Katie Musgrave is a GP in Devon and quality improvement fellow for the South West