Andrew Green: Asking GPs to peer review all referrals undermines professionalism

The suggestion that all referral decisions must be reviewed is a slur on the competence of GPs

andrew-greenWhen was the last time you came across the phrase “could reduce by up to . . . ?” An advert for an anti-wrinkle cream, perhaps? Or for some other consumer product? No, for me it was in a document by NHS England that called for the peer review of all routine GP referrals.

Many GPs are furious that NHS England continues to focus on access problems within secondary care, and appears unaware or uncaring about the crisis in general practice. Regarding variations in referral rates as a “problem that needs to be fixed” seeks to blame general practitioners for generating activity seen as unnecessary—distracting attention from the underlying problems that are caused by underfunding of the NHS as a whole.

The truth is that despite intense workload pressures, the vast majority of GPs endeavour to manage problems within primary care whenever possible. We also provide care for patients with many conditions, such as diabetes, the care of children, or the care of older patients in care homes, which in other countries are seen by specialists.

The decision to refer any patient is not made in isolation, based on a checklist of qualifying symptoms and signs. It is part of a complex process of management, which includes the person’s medical, psychological, and social situation. Referral decision making is an integral part of GP training and the suggestion that all such decisions must be reviewed is a slur on the education, competence, and professionalism of our colleagues.

This paper appears to take no account of the impact it will have on the ability of GPs to provide good quality care to their own patients. As an example, one of the schemes mentioned calls for daily meetings of 30 minutes each. Assuming each GP has around five hours of face to face consulting time daily, that would represent a reduction in clinical availability of 10%, which is roughly equivalent to removing about 3500 GPs from England’s workforce. Even if funds could be made available to resource this, and the other difficulties overcome, the lack of available GPs means that this scheme cannot be supported.

There is a real danger of undermining the trust between GPs and their patients. As soon as patients think that a recommendation not to be referred is based on anything apart from their best interests, they will seek alternative routes to a second opinion—not only for that condition, but for future ones as well. It is only the trust that patients have in their GPs that enables so much activity to take place in primary care, and any erosion of this will damage the entire NHS.

The suggestion that the highest referring 25% of practices will be initially subject to these measures is arbitrary, and cannot be justified without knowledge of the distribution of values across all practices and the absolute number of referrals made. Unless there is robust statistical analysis, there is a danger that some practices will be unfairly identified as high referrers, and the phenomenon of “reversion to the mean” will overstate the benefits of intervention, turning this into a self-perpetuating exercise.

It is true that a traditional outpatient referral is not always the best route for a patient to access further care, and I would support the provision of alternative services where these are patient centred and not designed to delay justified activity. If these are effective, well advertised, and accessible, then GPs and their patients will use them.

Inevitably, there are a small number of practices with referral rates that are sustained at a significantly higher level than other practices, and support to these practices aimed at understanding this difference will be far more cost effective than an untargeted approach. Such action must be restricted to genuine outliers, and be supportive and not punitive in nature.

Peer review of referrals already goes on in most practices, it’s called coffee time. Discussion between GPs of patients with complex or uncertain conditions is an essential part of high quality modern general practice, and these discussions extend to far more than just referral decisions. These habits will be nurtured by ensuring that GPs have enough time within their working day to meet informally with their colleagues, by working in stable supportive practices, and where they feel their professionalism is valued and has the opportunity to flourish.

Initiatives from NHS England should be aimed at ensuring these conditions exist. Unfortunately, this document will do the opposite, by undermining professionalism and increasing time pressures on general practitioners and their patients.

Andrew Green is a GP in Hedon, East Yorkshire, and represents GPs from East Yorkshire and Lincolnshire on the BMA GPs committee (England), where he is the clinical and prescribing policy lead. Twitter @drandrewgreen

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.

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  • Bill Anderson

    We have been at audit long enough for this not to be a surprise. The core business of medicine is advising patients and executing their decisions. A referral is but one example. If our colleagues think the referral was inappropriate it suggests we gave questionable advice on which the patient acted. Debate follows. Surgeons and others have been combing through their colleagues judgements for years. It is the norm. What is there to get excited about?