A value-based odyssey in Australia

Mandatory peer review of GP referrals - why this gets my goat

I see that referral management through peer review of referrals is doing the rounds again as the NHSE panacea for managing demand into secondary care. It is of course a well-intentioned attempt to ensure that we are using scant NHS resources wisely , but in the face of growing unmet needs in the community I am fairly certain that it will be an expensively futile endeavour.

Here is my ham-fisted attempt to explain why I believe this is so.

Referral for consultant opinion is one of the few tools a general practitioner has to help people get better from their symptoms and the reasons for referral can be divided up in a pretty straightforward way:

1. The patient has unexplained symptoms or there is diagnostic uncertainty.
Medical diagnoses are often difficult to make and do not come neatly wrapped in boxes. Clinical diagnoses (i.e. those made without a diagnostic test) are often particularly difficult and people may value an expert second opinion before embarking on treatment/to ensure nothing has been missed.

2. The diagnosis is suspected but referral is needed to access specialist diagnostic tests to confirm it. Sometimes these tests are negative - this does not necessarily denote post hoc that the referral was inappropriate and is why NICE has issued guidance on expected detection rate of cancers for referrals marked 'urgent suspected cancer'.

3. The diagnosis is confirmed and the GP has reached the limit of their expertise in managing the patient's condition or conditions. This may require access to a procedure that the GP cannot perform such as surgery or just advice on a possible next course of action eg the next step to take in improving control of type 2 diabetes.

4. The patient may request an expert opinion.

It is true that there is variation in GP referrals as part of a wider pattern of clinical variation in medicine. This is inevitable given that GPs have to know everything about everything and our core expertise is in managing uncertainty and complexity. However, having audited many hundreds of referrals from colleagues, it is plain to see that the days of 'Please see and do the necessary' are long gone and the majority are of a perfectly adequate quality, informed by national and local guidelines. Peer review can be a very useful educational tool but it will be completely ineffective at managing demand into secondary care. The reasons for unwarranted clinical variation are well rehearsed - see earlier blog. Spending money on mandating GPs to peer review all referrals will create a laborious bureaucratic exercise and the vast majority will go through rubber stamped in any case. Those that are not will create additional pressure on primary care as patients who thought they had been referred will have to be called back for an explanation of a change in management. I could go on...

I would suggest that what is required is a greater depth of understanding of referral variation at subspecialty level to understand the unmet needs of patients being referred in. If that is down to lack of expertise in primary care then let's figure out how to provide that advice and feedback loop systematically, by the experts! This can easily by done by email advice and has been successfully implemented in many areas. If it is down to a lack of community alternatives, then let's provide that - support on self management, pain management and support on shared decision making for preference-sensitive issues such as joint replacement are examples of this.
Let's take a whole system approach and examine the reasons for variation in outpatient follow ups too so that we can improve the patient experience at this end of things. As ever, people using our services provide invaluable insight into how we can do things better and reduce the burden of multiple attendances.

In the final analysis, all referrals are generated by unmet patient need. Let's figure out how to meet that need properly and not just put up the hand. Computer says no. If we don't , we will never evolve the NHS into an entity which can cope with the rising demands of healthcare in the modern world.