The Labour leader, Kier Starmer, in a piece published by the Telegraph and on the BBC last weekend said his party was going to tackle “bureaucratic nonsense” in the NHS and argued that people should be able to self-refer to a physiotherapist for back pain or to order a test for “internal bleeding” rather than having to see a GP.
The reaction on social media and in subsequent media articles was swift, with many medics appalled at the idea wondering if Starmer had actually spoken to any doctors. However, this opinion was by no means universal.
Dr Martin Brunet, a GP and medical educator from Guildford, said on Twitter: ‘Self-referral to specialists is a terrible idea. This is because primary care and secondary have a totally different approach since we see a different cohort of patients.”
In contrast Ed Turnham, a GP partner based in Norfolk, wrote on Twitter on why self-referral is possible in certain situations and if the right technology is used.
Although the NHS has developed over the years with the GP gatekeeping system in place and referrals from GPs being the only way to access a specialist, there are some notable exceptions, we self-refer for hearing tests and eyesight tests.
More recently, in many areas it has become possible to self-refer to a physiotherapist, for alcohol and drug treatment, stop smoking services and across England it is possible to self-refer for mental health treatment involving talking therapies. People can also go directly to clinics that deal with sexual health services and you can register for ante-natal care all without troubling a GP.
There is already a push from NHS England for more self-referral. In its planning guidance in December 2022, it states that systems should aim to:
“Expand direct access and self-referral where GP involvement is not clinically necessary.”
By September 2023, systems should be in place for the following:
direct referral pathways from community optometrists to ophthalmology services for all urgent and elective eye consultations;
self-referral routes to falls response services;
musculo-skeletal physiotherapy services;
audiology-including hearing aid provision;
weight management services;
community podiatry;
and wheelchair and community equipment services.
A quick look at these areas and it is clear that GP involvement is not necessary. Why would a GP referral be needed for a wheelchair or podiatry?
The complexities begin when self-referral to hospital-based consultants is considered. It is the possibility that this could happen that has caused the biggest outcry.
The example of “internal bleeding” used by Starmer, was perhaps not the best one to use as it is a symptom of many conditions.
However, there are other conditions, where the symptoms are not as general. Dr Ed Turnham, a GP and clinical advisor on digital strategy in Norfolk ICB, noted on Twitter “why not allow direct access for conditions such as breast lumps, where certain criteria are met?” and added “a GP appointment *might* save a referral to the breast clinic, but every time it doesn’t means 2 appointments where there could have been one.”
In the arguments on self-referral other country’s healthcare systems are often cited as examples where self-referral is possible. The most common example is France, however France has moved away in recent years from self-referral being the norm, to a system of GPs acting as gatekeepers. Now, although it is still possible to self-refer to specialists, there are financial incentives offered to those who opt to register with a GP or with a particular specialist, who can also act as a gatekeeper. About 95% of the population have chosen a GP as their gatekeeper.
Seeing a specialist without a referral from a gatekeeping doctor will cost the patient as there will be reduced Social Health Insurance coverage (there are exceptions).
Germany, another country often brought into the discussion, does not have a tradition of GPs acting as gatekeepers to the health system. The system developed with individuals having free choice among GPs and specialists, and registration with a family doctor is not required. However, the country’s sickness funds, which run the healthcare system, are required to offer members the option of enrolling in a family doctor (GP) care model, and they often provide incentives for complying with gatekeeping rules. Because of the way Germany’s healthcare system has developed, there are many more specialists so self-referral does not result in a long-waiting time.
In both France and Germany, although self-referral is no longer encouraged, the system has developed in a culture where it has always been possible. In the UK the population and specialists have always used a system of GP gatekeepers, and there are questions over how the population would react should more direct access be allowed and how specialists would cope with an influx of patients unfiltered by primary care.
There are concerns over people making unnecessary self-referrals that would mean restricting access for genuine patients, as Dr Martin Brunet noted on Twitter:
‘Clogging up the secondary care system with unfiltered primary care patients will make it harder for genuine secondary care patients to get access, with delays to diagnosis and treatment a significant risk of patient harm.’
However, Dr Clare Gerada, President of the RCGP, has noted that there is an argument to be made for allowing some patients with long-term conditions, such as in rheumatology, serious mental health and some cancers, self-refer back to the team that treated them at the start.
There are many questions over self-referral: how would a patient know what tests to order or which specialist to choose? How do you prevent patients choosing the wrong pathway for themselves – the wrong tests, the wrong specialist, which could slow down their time to treatment? How do you cope with those people for whom “Dr Google” is their guide and won’t listen to any other?
A major consideration will be cost. A systematic review published in the British Journal of General Practice in 2019 of 25 studies worldwide found that gatekeeping was associated with lower healthcare use and expenditure. The same review found it was associated with better quality of care, but with lower patient satisfaction.
Without some form of gatekeeping, cost containment becomes harder. One of the reasons France and Germany’s healthcare systems give incentives to register with a gatekeeping GP is that it is cheaper for the overall healthcare system. It is easier to contain costs if the number of patients who self-refer is kept low.
At the moment GP referrals are closely monitored as a way to control costs. Referrals are often turned down and sent back to the GP. For example in mental health, GPs have complained that the only way a referral will be accepted is if a patient has attempted suicide and often resort to recommending that a patient seeks private help as a referral will get rejected. How then will self-referral not lead to a massive escalation in cost for the NHS, as patients who could have been treated by the GP self-refer to specialists, bypassing all the checks and controls currently on GP referrals.
If specialists become inundated with patients self-referring, who they then have to assess for treatment, it will add time and cost to the procedure.
As Dr Martin Brunet outlines on Twitter, specialists and GPs see different cohorts of patients. GPs see many where initial treatment could be by the GP or a wait and see approach be taken, whereas specialists see a cohort that are at a different stage. He notes:
“Secondary care patients have already been screened as being more likely to have a serious problem and so it is right to consider all the possible causes, not just the probable ones and do the right tests to investigate them all…Self referral will lead to inefficiency, unnecessary tests (and associated patient harm) and huge costs.”
One possibility, outlined by Dr Ed Turnham on Twitter, is the use of technology to triage patients as part of the process of self-referral. He notes that there “is a huge opportunity to use technology-assisted triage to help patients go straight to specialists. This will provide more timely care, preserve NHS resources, and relieve strain from GPs…Direct access to consultant-led services would be for patients who meet tightly-defined criteria.” Such triaging would lead patients who do not fulfill the criteria back to their GP.
However, as Turnham points out such triaging will need considerable investment in IT, not something politicians like spending money on. And if self-referral is going to increase in any form, then a large investment is going to be needed in the workforce as well, otherwise the waiting lists will only lengthen.
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