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If we refer everyone, no one gets seen

If we refer everyone, no one gets seen

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



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

Just My Opinion 13 February, 2023 10:36 am

But if one, just one, of those referrals that you did not make is something serious, then the GMC and the medicolegal lawyers will tear you to pieces.
GPs value their careers more than keeping waiting lists down.

James Cuthbertson 13 February, 2023 2:26 pm

If a patient insists on referral I would refer them. Otherwise when inevitably harm comes to one of them (and not having immortality means harm does come to some of us) that non referral will be retrospectively analysed and destroyed (regardless of how much good you have done trying to keep the NHS afloat)

Anonymous 13 February, 2023 10:09 pm

Why is everyone so afraid to refer?
There is a reason behind the referral, all of them get screened. If you refer an absolute joke it will bounce. Where is the big deal?

Just My Opinion 13 February, 2023 11:29 pm

Many GPs have fallen for the propaganda that referrals are ‘bad’.
Referrals are not ‘bad’ – referrals are ‘expensive’.
And thats why NHSE wants to reduce them as they cost money.
Over time they’ve convinced more and more GPs that the reason they have to reduce their referrals is because somehow they are deterimental to patient care.
There is no evidence for this whatsoever.
In fact, a recent Kings report suggested referrals for cancer needed to be even higher than they already are, if we are to catch up with diagnosis rates in Europe.
So please, before you convice yourself that reducing referrals is somehow helping the patient, and that all this clinical risk you are taking on unnecessarily (which no one will thank you for when it goes wrong by the way) is worth it, look at the actual evidence.

Michael Green 17 February, 2023 6:45 am

Referring sets up a number of expectations by the patient which would be reasonable in any first world health system:

I will be seen in a decent time frame
I will be thoroughly examined and investigated by a specialist
I will receive a diagnosis, or, where there is no diagnosis, I will be told this in person
There will be clear and timely communication with me and my family doctor

Obviously none of this ever seems to happen. We have no functioning outpatient service. Instead:

Patient with barndoor migraines presents repeatedly, either refuses prophylaxis (I don’t want those chemicals in my body) or says they use but oddly last prescribed 2019
Patient is referred for headache because “I know my rights”. And hears nothing for weeks and months
Patient comes back to you repeatedly to chase referral, not necessarily because condition has worsened
Patient gets signed off “Headaches; awaiting super duper specialist opinion and cutting edge investigations”
Appointment letter arrives late, 12 months later, patient discharge as “DNA”. Re referred
Eventually seen 18 months later by specialist nurse, list of investigations for GP (already done – see the referral letter), instructions to re refer if significantly abnormal. No diagnosis, no treatment suggestions (which we could at least use as a lever given they come from the “specialist”. Nothing

So now I refer as little as possible. Not to “save the NHS” but because referring in is a complete ball ache, sets up unrealistic expectations and the backstop is always us.

The government will consider this a win.

Meanwhile in any functioning and well managed health service, we would be allowed to get on with the 90% of patients we can deal with, and secondary care (with 90% of the money, double the number of consultants than GPs, a figure which has doubled jn 20 years) will see the 10% we can’t deal with.

I’d even be happy to do more of the work done by, for example, some of the ridiculous one stop shop clinics set up in the last few years, if getting investigations “approved” by a radiologist (sitting in a dark room, never seen or laid hands on the patient, batting away every request with “specialist referral is advised”) wasn’t such a pain.

Why should I refer a patient to a nurse (£400 first appointment) in the fatty liver “clinic” who will invariably request a fibroscan and advise “GP to manage risk factors”? We would be happy to do the same with the same funding and resource..!

There are still departments in your local teaching hospital in primarily outpatient specialties with 20 consultants doing 1 x 2.5 hour clinic a week each with 3 new and 3 follow up appointments! When will this side of the equation be tackled?!

Cameron Wilson 17 February, 2023 9:02 am

Spot on, Michael! Should be essential reading for all those whizz kids that dream up the latest nonsense to deflect work!! NICE and ivory towered Professors included!!

Finola ONeill 19 February, 2023 10:34 am

Living in a parallel universe. Works in Devon? We don’t refer everyone. Can’t get anything past DRSS. Devon CCG have limited referrals. When was the last time any of us referred a patient due to their concern only? Bounced straight back. I can’t get patients I want to be seen accepted. And I don’t want access to imaging. I want specialist input. Most of the time I need brain power not imaging power. I’m speaking to patients up country who have had multiple scans done by their own GP with no treatment or diagnosis forthcoming. That is because diagnostics don’t diagnose. Diagnosticians ie clinicians do. I treat up to my knowledge base, and we are being stretched far beyond that at the moment anyway. When was the last time anyone referred to psych for anything? Just gets turfed back with a call the emergency advice number. I don’t want phone a friend. I want proper secondary care. This is a shit show.

Michael Green 20 February, 2023 10:13 am

Finola – what makes you think they once your referral has been accepted upon the holy grail of secondary care that a diagnosis (including – firm and confident “there is no known diagnosis) will be forthcoming?

No. A highly specialist advanced extended scope clinical practitioner will, if you are exceptionally lucky, see the patient, order every stupid serum rhubarb test under the sun, and then discharge the patient with instructions to talk to your GP.

There are no diagnosticians in secondary care. At least none seeing patients it would seem.

Simon Sherwood 20 February, 2023 7:36 pm

GPs not contributing much to the triage system is due to the toxic medicolegal regulatory machine, that means any complaint however ridiculous and divorced from reality will be viciously pursued by those that never have to do the job and couldn’t do it anyway.
However these people can end a GP career. What do you really expect front liners to do ?

To the author, unless you change this, your opinions will be ignored by those that wish to continue their registration.
Or by people like me, who left very early because of the stupid conflicting and impossible demands .

A Non 21 February, 2023 1:10 pm

If you think they need to be referred refer them. Do not flatter yourself with the idea you somehow have special powers in foretelling the future. You don’t. Sooner or later something ‘not ordinary’ will happen, something you really didn’t expect but should have prepared for will remind you of your fragility’ll roundly kick you up your arse and nobody will blame anybody but you. Nobody will mention the administrative letters asking you to ‘do your bit’ , nobody will reference the newspaper article by a hospital consultant suggesting GPs ‘over refer’ You will be completely and utterly responsible. Don’t be that well meaning fool