Referral Rejection Leads to Two-Tier Health System, Say GPs

Becky McCall

December 03, 2021

GP groups wrote to the Health Secretary, Sajid Javid, highlighting a predicament whereby secondary care referrals are being rejected, placing even more pressure on primary care and creating a two-tier NHS where, those that can afford it, obtain private care while the rest wait and suffer.  

The situation means patients require GPs to manage cases that require specialist attention and this sits outside of GMC guidance.

"The lack of GP access to secondary care referral pathways is not acceptable," say the 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 due to 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 might require pain medication or antidepressants during the interim.

Among calls to Javid from the doctors’ group, is a need for him to recognise the impact of these waits on primary care, and the need for greater resources; recognition that rejection of referrals must be the exception with a clear explanation and alternative plan provided; and that all rejection letters should be personalised and written directly to the patient, with the GP copied in.

They 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 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 says, "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 which could work ad hoc if this pension issue was sorted out."

Secondly, 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 both due to lengthy waiting times as well as referral rejection, say the DAUK. People who can afford it, look to private care to step into the breach, while 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 the trend towards private referrals highlights 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 that, "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 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."

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