No more GP referrals without 'peer review'

It seems to me that GPs are now being told that they are not competent to know if someone requires further investigation or treatment.

That is ridiculous. How on earth are GPs going to explain to their patients that they were apparently mistaken and somebody who has never actually seen the patient has vetoed their clinical advice! What are they then supposed to do?

Exactly Wildswan (lovely name!) no small wonder they are all retiring early, totally demoralising (and for the patient too!)

I was a Nurse Manager in the NHs for a long time and I've lived through the various 'privatisation' disguises put in by various governments. This kind of 'rationing' if you like has been going on in various forms for a long time. The problem is there are a lot of inappropriate referrals and out patients departments struggle to cope with the targets and the expectation of patients who quite rightly want to have their problem seen. Some consultants are notorious for holding on to their patients and having far more follow ups than their peers in the same speciality and this can be for several reasons many of them very good reasons.
There is also a strong feeling among many patients that general practitioners are only that, generalists,and they want a consultant appointment for everything but these days many GPs have had additional training and are clinical assistants in one speciality or another so your referral may initially be within the practice or in another nearby practice and not necessarily a hospital consultant straight away.
I don't have an answer to this very complex situation and indeed I don't think anyone does and therefore various 'fixes' are tried by managers of all types trying to make finite budgets stretch.
RAF I wouldn't dream of having a slanging match with you but as a subject feelings run high so you may get some vigorous debate on here.

I just feel so sad with the way the NHS generally is going ,but I do know people who think that everything can and will be cured, for free, and will be persistent until they are referred every test done.
8 times out of 10 there is no solution, well not one that satisfies them.

There is a lot of waste of appointments my neighbour has now had four different hospital appointments for the same thing that she hasnt turned up for including scans and X-rays whilst the problem is getting worse at the same time slacking the hospital off for not seeing her quickly enough She is also a heavy smoker which she is not prepared to give up Many people expect all sorts of tests and examinations for precious little There s a thread on here about taking more responsibility for yourself I think we need to stop expecting so much and also realise politically that the whole of the NHS is being privatised by the back door

Ann, I know someone like that. She is never happier than when she is awaiting an appointment or results.

We also have friend who is a retired gp whose referral rate was so high he was individually monitored. I think his nerve had gone.

I agree with Teetime's post.

When I was a GP we used to occasionally review our referrals together. It was done constructively and in a caring way. It sometimes helped to get others views on managing a particular problem and different avenues to explore. We have to do all we can to make sure
NHS resources are used in the best possible way.

Well at least the panel is other doctors.

DH had an excruciating pain in his arm last year. He had to stop driving, could not work and all various GPs suggested was paracetamol, which had no effect. When we pressed for a specialist referral we were told that a triage nurse at the hospital would ring him to decide whether he needed to see a specialist or not. A NURSE judging whether a doctor had made a correct referral.

We asked for a private referral. The specialist immediately recommended a standard neural pathway blocker for the pain, which the GP happily prescribed, until an MRI scan showed the problem was caused by damage to the top of his spine and he received suitable treatment. How would a nurse have worked that out over the phone?

I too have worked in the NHS for a long time (26 years) as nurse, practice manager, and PCT management. I still have a lot of GP friends who are utterly demoralised by the target culture and the the focus on cost cutting over patient care.

Whilst rationing will have to take place in some form because the Country cannot afford to pay for all the new and expensive treatments coming on the market, the wastage on setting up schemes like this breaks my heart. And having worked for a private firm given the contract to deliver a range of clinical services across London, I know how the complete focus on making a profit tops patient care in every private enterprise, how can it not?

If we are to ration healthcare, let's be honest about it and have a reasonable discussion with patient groups on what that rationing should entail, but don't privatise the NHS, that way spells disaster - look at the PFI initiatives!

I have recently been referred by a GP to a consultant. It has all gone through very quickly. A nurse who helps the consultant visited me at home and then got me a fairly quick appointment. This nurse comes to our house and monitors me. This morning she took blood (to make sure that the tons of medication is not damaging my liver and kidneys) and she phoned this afternoon to say the results are fine. I feel very well looked after on the NHS but am looking forward to them losing interest in me as I will know I am well on the mend then!

That is dreadful Bluebelle what a waste of time and money. Maybe the way to deal with this type of abuse of the system is to charge the patient concerned (unless there was very cause for not attending) and not make another appointment until the fine is paid.
I am in two minds about the smoking - I am torn between saying if people won't help themselves by stopping or changing lifestyle with assistance - depending on the problem - then treatment should be modified. An example of what I mean is giving a liver transplant to an alcoholic who just continues to drink and abuse the new liver.
I can also see that they are ill whatever the cause and need help.

I completely agree with you RAF. This GP "secondary vetting" has been in operation in my area for some time, and it is clearly about cost cutting and unfortunately no government is willing to be open and willing to have an honest debate about affordability. My concern is not the occasional time wasters who abuse the system but the number of those who visit their GP several times before referral and are subsequently found to have a cancer diagnosis or life threatening condition.

I think I read recently that GP's will be having less training as they need to get more GP's working at practices due to shortages; my first thought was that, the less experience a young GP has, the more likely they will be to refer patients unnecessarily. However, I'm afraid I can't find the article I read to confirm it. I know we had some doctors who referred everybody for everything and some who hardly ever referred anyone [even when they should have]. Maybe some sort of joint decision wouldn't be a bad thing, but would then involve more time and paperwork etc.

So supposedly there's a problem with GPS ability to refer appropriately. What an excellent way to solve it by making patients wait even longer. The NHS has all the data it needs on referral rates of individual GPS and practices. It also has the date about outcome of referrals. It should be working with that data to provide appropriate training and guidance to practices as necessary. That way money and resources may well be saved but not at the cost of patients waiting and worrying

This has been trialled in the north east, including my area. All the GPs who dare say anything think it's a waste of time and money, and dangerous.
I remember hearing George Rae, a member of the BMA council, and a Street Doctor, complaining that someone with an aggressive cancer had been referred to this group, and it put his treatment back by weeks.

In theory it is not supposed to affect the two week waits, but as you say Durhamjen, some won't make it through in time.

When we put GPs in charge of running the NHS, they didn't want to do it, and subcontracted to managers. Nearly all of them just want to give their patients the best care they can, they don't want to spend their time producing reports to meet targets and attending meetings.

We need an honest discussion on what the NHS can afford and develop a national policy to decide and inform on what it cannot. Postcode lotteries on where you can get fertility treatment and how many cycles, whether your varicose veins will get done, how bad you have to be for a knee replacement have no place in a National health service.

Meanwhile GPs are being made to waste money sending patients for all sorts of intermediate treatments, just in case they work, even when it is quite clear that the condition has reached a stage where surgery is the only option.

I am being treated for carpal tunnel syndrome. Both my GP and consultant agree that it so advanced that only surgery, a very minor day operation, will sort the problem out, but NHS guidelines mean that I have had to have a steroid injection and now further tests, just to see if it might respond to lesser treatments.

Nobody expects them to work and they haven't. But they have probably cost the NHS £500 that could have been saved by accepting what both GP and consultant said from the start. That the condition has reached a stage where surgery is the only option.

RAF I look down the other end of the telescope. It's not about what the NHS can afford, it's about the political will as to how much the government is prepared to fund it from taxation. We could double our spending on the NHS if we wanted to simply by increasing taxation or not spending in other areas

Part of the problem is the fear of litigation which we seem to have inherited from the US

In N Ireland the politicians are being a pain in the a** and are not 'sitting'.

Therefore nothing is being done, budgets are not being managed. No money (which is theoretically available) in the budget is being moved/processed.

So.... one person I know is taking up a bed in a major hospital. He wants to go home, the hospital want to discharge him but he can't go home without a care package being set up. There are no... absolutely no care packages available. There is no money. Well, actually there is money, but it hasn't been passed over to the NHS because our representatives in government can't agree and aren't 'sitting'.

Same for consultations at hospital, surgeries etc.
Not only were we suffering the usual NHS cutbacks but we are now facing deadlock as the money cannot be accessed.

Sorry, rant over.
Apologies for the mention of politics....

www.opendemocracy.net/ournhs/david-wrigley/second-guessing-your-gp-s-referral-nhs-denials-leave-big-questions-unanswered

Government is saying it's not true.
Doctors are angry at the idea.

This seems much the same as the referral management centres we already have, some of which help and some of which slow things down considerably. I worked in a similar service and we saw patients within a week and organised scans etc. so they could then be sent on to surgery, physio or whatever was best. However, when I needed to go to gynaecology, there was over a month's delay with the referral management service.

We urgently need some sort of cross party think tank on what we as a country can afford to spend on N.H.S. It is something that could soak up billions and billions in future years because of new treatments as well as obesity epidemic and poor health due to poverty. (I am not in favour of privatisation.)