Lack of access to secondary care referral pathways is placing even more pressure on GPs, who are ‘keeping patients going’ until appointments become available

A stressed male doctor with his head on his hands behind a pile of work.

GP groups have written to the Secretary of State for Health and Social Care, Sajid Javid, highlighting the fact that secondary care referrals are being rejected, placing even more pressure on primary care, and creating a two-tier NHS in which those who can afford it obtain private care while the rest wait and suffer.  

The situation means that GPs are required to manage patients who need specialist attention, and this sits outside of General Medical Council (GMC) guidance.

‘The lack of GP access to secondary care referral pathways is not acceptable’, say medics from The Doctors’ Association UK (DAUK), Doctors for the NHS, GP Survival, and 999 Call for the NHS.

Waiting time pressures that existed prior to the pandemic have been exacerbated by the added stress of the NHS backlog and other demands of COVID-19-related care, including the UK’s booster program.

GPs are effectively ‘keeping patients going’ until secondary care appointments become available—for example, someone waiting for a joint replacement may require pain medication or antidepressants while they wait to see a specialist.

The doctors’ groups have called for Javid to recognise:

  • the impact of these waits on primary care, and the need for greater resources
  • that rejection of referrals must be the exception, with a clear explanation and alternative plan provided
  • that all rejection letters should be personalised and written directly to the patient, with the GP copied in.

They also request that Javid visits their practices to understand first-hand the pressures they work under, and listen to the solutions. ‘Some things need decades to remedy, but there are quick wins too’, says GP Lead for DAUK, Dr Lizzie Toberty.

Heavily mandated 

One of these is halting all moves to mandate Advice and Guidance (A&G), whereby a GP can phone a secondary care doctor and ask for rapid advice on various aspects of care, from blood tests to referral.

Toberty welcomes A&G broadly, but believes that recent changes to the A&G system present challenges. ‘It appears to be so heavily mandated that GPs are being prevented from referring onwards when required.’

She states, ‘If a GP has decided a referral is necessary, and the situation is outside their competency, then they must refer onwards, in line with GMC advice.’ However, she adds, ‘allowing specialists who have not assessed the patient themselves to make the decision whether a referral is justified is not in keeping with the current emphasis on face-to-face consultations, and risks patient safety.’

Toberty says that, in her practice, she is seeing a huge rise in the number of rejected referrals. ‘This is very difficult to manage … because you are being asked to step outside of your competency to manage that condition, which is not only against GMC guidance, but against the general principles of the NHS, and will lead to an unsafe system.’

Among quick wins under the current scenario, Toberty asserts that shortages in the medical workforce is central, including key issues around pensions, revalidation, and bureaucracy. ‘GPs and consultants in their 50s and 60s have issues with pensions whereby working more hours is costing them money, and there’s no fix for this currently’, she said, stressing that ‘there are lots of doctors around retirement age with a wealth of experience [who] could work ad hoc if this pension issue was sorted out.’

Also, she adds that appraisals and revalidations are ‘massive barriers to continued working because doctors don’t want to go through the process again’. Toberty would like to see more flexibility because ‘these people are so precious to our NHS, especially now, when we are short of essential workforce.’

Private referrals rise 

GPs are also seeing a huge increase in demand for private referrals, because of both lengthy waiting times and referral rejection, say the DAUK. People who can afford it look to private care to step into the breach, whereas those without the means are left to suffer.

‘The NHS is becoming a two-tier system, with lack of referrals and long waiting lists forcing an inequality of medical care within the population’, says DAUK.

Speaking for Doctors for the NHS, Alan Taman said that the trend towards private referrals highlights a lack of long-term investment in the NHS. ‘This demonstrates the critical need to invest in the NHS and redress problems over staffing, which have been building for years and will take years to resolve.’

However, he adds, ‘People should not have to face paying for their own treatment because they will otherwise have to endure waits of months to years—or can no longer get treatment from the NHS because it has been cut.’

Over the long term, Toberty adds that better appreciation of the medical workforce underpins much of the current crisis scenario. ‘Staff need to feel appreciated, from pensions to hot food on overnight shifts. When people feel appreciated and feel that they belong to a team, they stay. We need to look not only at recruitment, but at what to do to retain staff and make them feel valued.’

This article originally appeared on Medscape, part of the Medscape Professional Network.

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