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Second-guessing your GP’s referral - NHS denials leave big questions unanswered

Despite attempts by government to squash the ‘NHS referral scheme’ story, senior doctors have serious concerns about the damage the proposed scheme will do to the NHS, people’s health and to the doctor/patient relationship.

 

Image: Flickr/Lucas Moratelli, Creative Commons

The latest idea from NHS England has got doctors really angry – and it takes a lot to do that these days, given the familiarity of relentless attacks on the profession and the health service itself.

NHS England are to ask CCGs to put every referral from a GP through a new vetting process before they reach the specialist they were intended for, according to a leaked memo of the secret plans. The term for this is ‘referral management’ (there are a few exceptions to this scheme, like urgent or suspected cancer referrals).

Since 1948 GPs have been at the front line of NHS healthcare. Every UK citizen has the right to register with an NHS GP and that GP is the first port of call if you are unwell or feel worried about your health. Often your GP would undertake further tests or investigations to try and diagnose the illness you presented to them. Sometimes it isn’t possible to confirm a diagnosis and your GP would decide to refer you on to a hospital specialist for their opinion, further investigations and / or advice and treatment.

So why is NHS England saying that all such referrals now have to be second-guessed by a panel who haven’t even seen the patient – with the suggestion this scheme could reduce referrals by up to 30%?

In today’s NHS these referrals have pound signs attached to them. Every GP referral is seen by NHS England as another burden on the NHS budget and they are now looking at ways to reduce those referrals to hospital doctors. NHS England focuses on the pound signs but seem to forget that behind those referrals are real people with real problems who have already seen their GP, often many times, and in need of the help of a hospital specialist.

The former head of the Royal College of GPs, Maureen Baker, said in response that she is “concerned about the patient safety implications of referral management” and asks “what – if any – risk assessment has been done?”

Hospital doctors are also deeply concerned, with the President of the Royal College of Physicians sayingVetting GP referrals to hospital is disempowering. There must be better ways to reduce outpatient attendances.”

The BMA spokesperson, Dr Andrew Green, is similarly scathing: We are used to seeing un-referenced claims such as ‘could reduce by up to’ in adverts for anti-wrinkle cream and I am surprised to see such language in an official document.” And he adds “It is important to be aware of the lost-opportunity costs of schemes like this, if we assume an hourly weekly meeting that would be equivalent to removing 1000 GPs from the English workforce, GPs we don’t have.” 

But the loss of GP time in vetting the referrals is also lost on NHS England, it seems.

We live in a country that is the 5th richest in the world  and has an NHS that is the envy of the world despite funding shortfalls that have pushed it close to collapse.

Usually restrained commentators are now raising concerns over this new scheme. Jeremy Taylor, CEO of National Voices, a coalition of health and social care charities, tweeted “Has NHS England consulted anyone? Eg have any patients or patient organisations had any say in this?”

Rather than face up to the criticism, NHS England seems to be hoping that if it fudges things enough, the storm will blow over. NHS England have their own ‘media’ twitter account (@NHSEnglandMedia) to highlight issues and rebut adverse publicity. On 29th August, the media account was concerned enough to tweet on this hot topic.

Alongside a shot of the Daily Mail front page headline ‘GPs told to slash hospital referrals’ the NHS England media account  claimed that it was ‘Inaccurate nonsense from tomorrow’s Daily Mail’. In another sign of their sensitivity about this issue they even managed to get a rapidly published ‘clarification’ from the Daily Mail – something that some might see as harder than getting blood from a stone. The article published just 2 days later read:

But this claim feels like a frantic fudge from NHS England’s PR team. Despite numerous requests (including from myself and other high-profile experts), NHS England themselves have pointedly refused to explain publicly how GPs will ‘retain final responsibility’, overturn decisions if there is disagreement, or avoid delays. Many have pointed out that the experience of GPs in areas where ‘referral management’ has already been introduced, is that whatever the spin, these schemes do, in reality, override the GPs decisions.

Dr Steve Kell, former co-chair of NHS Clinical Commissioners is one of those expressing concern. He tweeted “Making schemes mandatory is new – we’ve never had one. Lots of twitter noise but no actual guidance yet. Hope someone is watching.” In response to his questionSo can we refer BEFORE the referral is reviewed?” NHS England Media account merely replied “We will check for you. Please can you DM your contact details”. Kell is still asking questions, including “what about…right to a second opinion and confidentiality?” so we can assume he’s not satisfied.

The foundation of the centuries old doctor patient relationship is one of trust and this is why doctors remain one of the most trusted professions in the UK. For patients to find out they have been denied treatment will make them wonder about the reasoning for this. As Professor Martin Marshall, Vice Chair of the RCGP, said in a statementour concern is that these schemes can undermine the important trust that exists between GP and patient.”

As things stand now if your GP feels you need a consultant opinion they will sort this out for you and an appointment will eventually arrive on your doormat. Under the new system the GP will not be sure if their referral will get through the ‘vetting process’. Highly trained GPs with years of experience will have to cross their fingers that their referral gets through the system. They will not be able to say to you in the consultation that you will definitely get an appointment. Its yet another stress and burden for GPs – many of whom are leaving their profession in droves. The stress for patients will be evident too and it will raise suspicions by the patient if a GP says ‘I don’t think you need to see a specialist for this problem’. If your referral is knocked back will you wonder whether your local NHS is trying to save money from its already stretched budget?

And in the long run the measure is likely to be entirely counter-productive. As Kailash Chand OBE, honorary Vice President of the BMA, says “if people are denied hospital treatment, then their health will invariably be compromised…In the long term, this measure will therefore end up costing the NHS more money and waste further time”. 

GP and assistant medical director of NHS Wales Sally Lewis agrees, blogging that these ‘referral panels’ will “create a laborious bureaucratic exercise” and “be completely ineffective at managing demand into secondary care” and concludes: “In the final analysis, all referrals are generated by unmet patient need. Let's figure out how to meet that need properly and not just put up the hand. Computer says no.”

GPs need to speak out about this latest idea from Whitehall and patients need to write to their MPs to tell them they want the NHS to be funded adequately for the care they need and stop inventing new ideas to prevent their necessary care.

More and more cuts to care are occurring and we must fight back or the NHS as we know it will be lost for good.

 

About the author

Dr David Wrigley (@davidgwrigley) is a GP in Carnforth, Lancashire and campaigner on the NHS. He co-wrote the recent book 'NHS for Sale' and contributed to ‘NHS SOS’ – all profits of which go to Keep Our NHS Public.


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