Only a tiny fraction of the ocean of human physical and mental suffering reaches the shores of general practice, from where barely ten per cent of patients are referred for specialist attention. GPs have been trusted to refer judiciously, according to their clinical judgement, saving time and costs of specialist interventions. This gatekeeper role is widely acknowledged to be a key feature of the NHS, which keeps it at the forefront of cost effectiveness internationally.
In recent years, however, the rate of referrals began to rise – the opposite of NHS England’s strategic aim of shifting care away from hospitals. Some commissioners have been offering financial rewards for reducing the rate,((GP referrals drop for the first time in six years – Elisabeth Mahase, February 2018)) a measure which many GP feel is unsafe. The reason for this situation lies in a basic policy conflict.
Since the Conservatives took power in 2010, NHS funding has been practically at a standstill, while costs have risen at a steady 6-7% per year, leading to the present catastrophic deficits with correspondingly desperate cost-cutting interventions. At the same time there has been an unprecedented focus on patient safety, resulting ironically, and tragically, in a culture of fear – reaching its zenith in the recent case of Dr Bawa Garba, a paediatrician who was struck off after a child died while she was working under in an understaffed department without senior cover. A culture of fear is overwhelming attempts to cut costs by doing less. Fearful of missing a rare diagnosis, GPs are investigating more than ever; fearful of a delayed diagnosis of cancer, GPs are referring more than ever; fearful of patient complaints, GPs are prescribing more than ever – with very few exceptions.
At a political level there is a refusal to acknowledge that the problems of high rates of investigations, referrals and prescribing are a consequence of fear, stress and overwork. It is impossible to do less if you do not have time to think more. The quadruple aim((The Triple Aim or the Quadruple Aim? Four Points to Help Set Your Strategy – Derek Feeley, November 2017)) of improving patient and professional experience and the health of the population while decreasing costs has been in practice a single aim of reducing costs. By almost every measure, the other three aims (shown by the British Social Attitudes Survey((Public satisfaction with the NHS and social care in 2017: Results and trends from the British Social Attitudes survey – Nuffield Trust / King’s Fund, February 2018)) and recent reports into the health of children((State of Child Health – RCPCH, January 2017))) have worsened significantly. The only thing the government has succeeded in doing is screwing up (or down, depending on your perspective) the costs.
A few years ago I audited referrals of patients with headaches to our local neurology clinic. I read the referral letters to see if the reasons for referral were clearly stated and if there was sufficient detail about the clinical features, the treatment history, the social context and the patient’s concerns. Many letters had inadequate information and others were comprehensive but were about problems that a competent GP ought to be able to manage. Unsurprisingly all these ‘unnecessary’ referrals came from a handful of practices. We invited representatives to an ’education session’. The session was run by a neurologist to present the expert view while I was there to help think about some of the psychological reasons behind referrals. I told the group how, as a junior doctor working in A&E several years before, I had sent home a young man with a headache who was readmitted after my shift, unconscious and fitting. He had suffered a subarachnoid haemorrhage – a bleed from a vessel in his brain. I nearly gave up medicine then, right at the start of my career, and was very anxious about managing patients with headaches for years afterwards.
About a year before the education session I had met another patient who had suffered subarachnoid haemorrhages and together we spent several sessions teaching medical students about headaches. This way I got over my fear and became our practice lead for headaches. By sharing this at the session I helped the other doctors in the room to think about their own lack of confidence. A year later, referrals from the doctors that came from the practices represented at the session had reduced by between 50 and 100%.
The use of financial incentives to reduce GP referrals reveals a failure to recognise the complex reasons behind a referral. If I am anxious, stressed, rushed and lack time to think carefully and critically, it is much easier to refer patients so that they become somebody else’s problem. Working in the NHS in a time of austerity and digital technology I find myself with less time than ever to reflect or discuss cases with colleagues, while it is easier than ever before to order a wider range of tests. We need to shift our focus of attention onto the experiences of patients and health professionals and the quality of referrals and the outcomes, and then see what that does to cost effectiveness, not the other way around.