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You can find the current article at its original source at https://www.theguardian.com/commentisfree/2017/aug/31/gp-vetting-hospital-referrals-help-patients-nhs
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| As a GP, I’ve seen how vetting hospital referrals can help patients | As a GP, I’ve seen how vetting hospital referrals can help patients |
| (8 days later) | |
| The latest scare story about the NHS suggests that GP referrals to hospital will be increasingly vetted by a panel of other doctors who will have the power to refuse or allow patients access to specialist services. The NHS is rolling out a scheme that requires all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals, including hip and knee surgery, cataract removals, X-rays and scans. The “peer review” scheme is being expanded nationwide from next week following a pilot in two regions in the north-east. | The latest scare story about the NHS suggests that GP referrals to hospital will be increasingly vetted by a panel of other doctors who will have the power to refuse or allow patients access to specialist services. The NHS is rolling out a scheme that requires all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals, including hip and knee surgery, cataract removals, X-rays and scans. The “peer review” scheme is being expanded nationwide from next week following a pilot in two regions in the north-east. |
| Is this a good or bad thing? Should we rethink the gatekeeper role of GPs? Will this scheme make it harder than ever to get to see a specialist? Or will it help to streamline the referral process so you get to the right service in a shorter time? | Is this a good or bad thing? Should we rethink the gatekeeper role of GPs? Will this scheme make it harder than ever to get to see a specialist? Or will it help to streamline the referral process so you get to the right service in a shorter time? |
| The truth is, some kind of referral management system is already in place in many parts of the country, including the area I work in as a GP. So far today, I’ve seen 28 patients and made two hospital referrals – one to urology for a man, let’s call him “Ted”, who might have prostate cancer, and the second to orthopaedics for “John”, who has severe arthritis of the hip and needs a hip replacement. Ted will be seen within two weeks because all suspected cancer referrals are dealt with by a centralised system that ensures a prompt triaging system. John’s appointment will take longer and will go via a referral management system that screens every routine and urgent referral that GPs make in my area. | The truth is, some kind of referral management system is already in place in many parts of the country, including the area I work in as a GP. So far today, I’ve seen 28 patients and made two hospital referrals – one to urology for a man, let’s call him “Ted”, who might have prostate cancer, and the second to orthopaedics for “John”, who has severe arthritis of the hip and needs a hip replacement. Ted will be seen within two weeks because all suspected cancer referrals are dealt with by a centralised system that ensures a prompt triaging system. John’s appointment will take longer and will go via a referral management system that screens every routine and urgent referral that GPs make in my area. |
| Most healthcare in the UK is delivered in primary care. Everyone wanting to access secondary care (usually hospital-based consultant teams) has to go via a GP. Most private health insurance companies require a GP referral too. The only way to bypass GPs is to pay a specialist yourself, and even then most will ask for details from the GP. People who come from countries where primary care isn’t well developed, and where the rich are used to accessing specialists as they would buy any other service, often find this GP gatekeeper idea frustrating and unnecessary. | Most healthcare in the UK is delivered in primary care. Everyone wanting to access secondary care (usually hospital-based consultant teams) has to go via a GP. Most private health insurance companies require a GP referral too. The only way to bypass GPs is to pay a specialist yourself, and even then most will ask for details from the GP. People who come from countries where primary care isn’t well developed, and where the rich are used to accessing specialists as they would buy any other service, often find this GP gatekeeper idea frustrating and unnecessary. |
| In time – hopefully soon – people will hold their own electronic medical records, as they do in Estonia. But in the meantime, GPs hold the only complete medical record and any decent referral to a specialist will include a complete summary of your significant past medical problems, current medication, allergies and investigations. The best sort of GP referrals will be asking the specialist a specific question that the generalist can’t answer or requesting access to investigations and treatments that aren’t available in primary care. GPs are usually also good at understanding what’s available locally and signposting you to the appropriate specialist service. | In time – hopefully soon – people will hold their own electronic medical records, as they do in Estonia. But in the meantime, GPs hold the only complete medical record and any decent referral to a specialist will include a complete summary of your significant past medical problems, current medication, allergies and investigations. The best sort of GP referrals will be asking the specialist a specific question that the generalist can’t answer or requesting access to investigations and treatments that aren’t available in primary care. GPs are usually also good at understanding what’s available locally and signposting you to the appropriate specialist service. |
| So if GPs are so good at making and directing referrals, why not trust us to send our referrals directly? Why introduce another tier that scrutinises the referrals? Doesn’t that just waste money and cause further delay in an already sluggish system? | So if GPs are so good at making and directing referrals, why not trust us to send our referrals directly? Why introduce another tier that scrutinises the referrals? Doesn’t that just waste money and cause further delay in an already sluggish system? |
| Well, yes and no. It is unbelievably frustrating to GP and patient alike to have referrals send back with notes saying “insufficient clinical information”, “full blood count result needed”, “please follow guidelines on fertility referral and then resend”. The conscientious GP will do their utmost to follow guidelines and supply all the necessary information with the initial referral. And if it gets bounced back with a request for more information, will supply it promptly. But GPs vary in quality and efficiency and some referrals that get bounced back languish in in-trays while the patient waits for an appointment, unaware that it is yet to be processed. | Well, yes and no. It is unbelievably frustrating to GP and patient alike to have referrals send back with notes saying “insufficient clinical information”, “full blood count result needed”, “please follow guidelines on fertility referral and then resend”. The conscientious GP will do their utmost to follow guidelines and supply all the necessary information with the initial referral. And if it gets bounced back with a request for more information, will supply it promptly. But GPs vary in quality and efficiency and some referrals that get bounced back languish in in-trays while the patient waits for an appointment, unaware that it is yet to be processed. |
| The referral management system represents an excellent way to ensure efficient and equitable use of specialist resources | The referral management system represents an excellent way to ensure efficient and equitable use of specialist resources |
| On balance though, the referral management system represents an excellent way to drive up standards of referral and ensure efficient and equitable use of specialist resources. The days when a GP could write a referral letter that only says “Dear Doctor, Please see this 48-year-old woman with breathlessness” are long gone – and rightly so. | On balance though, the referral management system represents an excellent way to drive up standards of referral and ensure efficient and equitable use of specialist resources. The days when a GP could write a referral letter that only says “Dear Doctor, Please see this 48-year-old woman with breathlessness” are long gone – and rightly so. |
| So the idea of a panel to scrutinise referrals is not necessarily bad. But there are a few caveats. The panel needs to follow pathways, but in a nuanced and flexible way. There needs to be wriggle room for unexplained symptoms and particular concern by the doctor or patient, even if the situation doesn’t fit in with guidelines. | So the idea of a panel to scrutinise referrals is not necessarily bad. But there are a few caveats. The panel needs to follow pathways, but in a nuanced and flexible way. There needs to be wriggle room for unexplained symptoms and particular concern by the doctor or patient, even if the situation doesn’t fit in with guidelines. |
| And patients who fear that their GP is not acting as an effective advocate on their behalf, and that the referral is sitting at the bottom of their to-do list, must be able to take action. An app allowing you to track the progress of a referral, in the same way that you can track your Amazon delivery, would be ideal. Until that happens, if you’re waiting for an appointment that hasn’t arrived, check with your GP surgery. Ask where and when the referral was sent and what the expected timeframe is – and get your NHS number from them. Choose and Book operates in many areas, allowing you to book online. If a referral management system is in place, get their email and contact them. Or if the referral has been sent directly to the hospital, their patient advice and liaison service team can investigate unreasonable delays on your behalf. | And patients who fear that their GP is not acting as an effective advocate on their behalf, and that the referral is sitting at the bottom of their to-do list, must be able to take action. An app allowing you to track the progress of a referral, in the same way that you can track your Amazon delivery, would be ideal. Until that happens, if you’re waiting for an appointment that hasn’t arrived, check with your GP surgery. Ask where and when the referral was sent and what the expected timeframe is – and get your NHS number from them. Choose and Book operates in many areas, allowing you to book online. If a referral management system is in place, get their email and contact them. Or if the referral has been sent directly to the hospital, their patient advice and liaison service team can investigate unreasonable delays on your behalf. |
| • Ann Robinson has been a GP for 16 years | • Ann Robinson has been a GP for 16 years |