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GPs’ supposed ‘three strikes’ rule on referrals is a complete myth



Jeremy Hughes, chief executive of the Alzheimer’s Society, has some explaining to do.

I’m not one for singling out the behaviour of one individual, but his comments about GPs at the King’s Fund on Tuesday were a real low point in an otherwise excellent conference on dementia.

On the basis of the comments of an unnamed ‘GP friend’, Mr Hughes claimed that GPs operate a ‘three strikes and you’re in’ policy whereby they were ‘taught’ to only refer a patient after seeing them at least three times in order to ‘balance the books’.

Pulse readers won’t need me to tell them how wildly misleading this is. I can’t say whether or not Mr Hughes was told this by a GP.

But that claim is so plainly wrong that it beggars belief that Hughes could deliver this cynical overstatement as truth to a packed room of delegates, all of whom are trying to improve the care of patients with dementia.

Seething in my seat, I challenged Mr Hughes about it on Twitter, stating that it was simply not true that GPs were ‘taught to see someone three times before they refer’.

He replied: ‘Good GP training improving, but too many people still report repeated visits to GP and much distress before diagnosis referral’

So now he asserts that GP training is ‘improving’. But does he know anything about that subject either?

Has Hughes ever visited a VTS scheme to see how we are trained? Would he like to visit mine?

Would he like me to make sweeping, ill-informed comments about how Dementia Navigators are trained by the Alzheimer’s Society?

No, I suspect he wouldn’t, and nor will I – because I know nothing about it.

Whether or not to refer a patient to secondary care is a complex business involving ethics, the balance of benefits and harms, clinical urgency and patient preference. GPs have never been taught to ration care on the basis of his ‘three strikes’ assertion, and it is ludicrous to claim otherwise – as a GP trainer for over 10 years and a Programme Director for nearly five years, I consider myself qualified to say so.

Yes, there are times when GPs could and should have referred sooner, of course. But this is not the same as saying we are taught to deliberately delay a referral in order to balance the books.

If we are to improve the care of people with dementia, it would really help if Mr Hughes could stop making wild claims about the inadequacies of GPs, and start listening to us instead.

Sadly, he shows no sign of doing this. In his closing remarks, he criticised his own GP practice for installing a self-check-in machine at reception, declaring it to be ‘most un-dementia-friendly’, since patients with dementia would struggle to operate it.

Had he asked any of the GPs in the audience, we could have told him that patients with dementia can still check-in in the usual way.

Moreover, we could also have told him that since the introduction of these machines, practices have experienced shorter queues at reception – meaning they have more time to help someone who might have dementia.

But he didn’t ask us, did he?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.