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We must help risk-averse younger GPs to cut unnecessary referrals

After April 2013, the number of referrals made by GPs at a practice will become a serious matter for every partner. Of course, it has always been an important matter for patients, with some people benefitting from an appropriate referral, and others suffering when a referral might have been avoided through reassurance, advice or action by their GP. 

Every practice, as a member of a CCG, and every partner will have to take on the responsibility for making the best possible use of resources. In short, the more referrals you make to secondary care, the less money there will be for primary care or for redesigning services so that they can be provided more locally. Any action that reduces inappropriate referrals and makes the referral system more cost effective will not only benefit patients and CCGs but also GP practices and partners.

My experience is that if you look at referrals made by partners in a practice, they tend to have a linear relation to the partner’s age and experience, with younger partners referring more and older partners tending to refer less. 

There are numerous reasons. Part of it is that older and more experienced partners have encountered a wider range of conditions and problems and can often deal with them without referral.

Older partners were also brought up in a tradition whereby ‘tolerating uncertainty’ was one of the recognised features of a good GP. By contrast, junior partners might view ‘tolerating uncertainty’ as ‘tolerating unnecessary risks’. 

Older partners might be less defensive in their medicine as they have less to lose from complaints and court cases than those just entering general practice. Older partners are more used to ‘making do’. 

When I started in general practice, I had to make do with access to just half a local cardiologist whereas now I can contact five or six. We recognised that specialist time was limited and rationed patient access accordingly. Old habits die hard, especially when older partners are sometimes less up to date with NICE guidelines than their younger partners. 

This does not imply that the older and lesser referrers are right and the younger and more frequent referrers are wrong. The truth, almost certainly, lies somewhere in the middle. It does mean, however, that older and more experienced partners may be able to help those younger partners who are referring substantially more than the average for general practice. 

Offering support

As older and more experienced GPs, we have a duty to support our younger peers in navigating the contradictory forces of increasingly demanding and litigious patients, endless guidelines, a cash-strapped NHS and the fundamental wish of every doctor to do their best for every patient.

An important start is for GPs to leave their doors open to junior partners. In our practice, we have a half-hour coffee break every morning where, at least in theory, we aim to discuss referrals made by the different partners that morning with a view to seeing if they are necessary. We audited this in its early days and found we had reduced referrals by almost 20%. 

When we looked at individual patient referrals within our own practice, we found that better quality of service to the patient and reducing referrals went hand in hand. This finding was similar to how reducing prescribing costs in the old days (particularly for antibiotics) often went hand in hand with better medicine.

Creating systems of peer review to enable younger and more inexperienced GPs to refer less is not simply about saving money but also about improving the quality of care and improving support and job satisfaction for younger colleagues.

By helping younger partners in this way, we will be avoiding the unpleasant alternative options. These might include each practice being given a quota of referrals, a draconian and externally imposed referral management system, reduced services with longer waits or punitive measures on GP practices that refer more than average.

And on the plus side, we will be contributing towards better care, happier and more fulfilled younger partners and the overall sustainability of the NHS. 

Dr Michael Dixon is chair of the NHS Alliance and a GP in Cullompton, Devon