What happens when you are referred to a specialist by a GP?  

(Well mainly you wait – but for increasing numbers something much better may be happening).

Yesterday I mentioned that over 1.6 million people are referred by GPs and added to waiting lists very month.

That’s a lot of people.

One of my medical friends describes what happens when a GP refers a patient to a specialist as a sort of relay race where the patient is the baton. You leave the warm hands of one part of the health service and are passed onto the warm hands of another part of the same service.

That’s fine – so long as the race lasts for at most a few minutes – but if that passage takes a year then, from the baton’s point of view, I would feel that I had been dropped and forgotten.

What do you do with this experience? You went to your GP because you were worried. The GP, in as kind a way as possible, has confirmed your concerns by saying that they think you need to see a specialist, or need some tests.

Then you waited.  And mostly you heard nothing. After a while you might begin to worry about the postal service – did the referral get through? (Or if you know more about the NHS you worry that the fax did not get through).

After a while, if you are lucky, the organisation to which you have been referred will tell you that you have a date for an appointment in a few months’ time. This is a breakthrough because now you have someone to phone and talk to. As a patient you have been passed on.

But others just don’t hear.

And, of course, worry.

For some, after a few months more, they see the specialist, have the test, or get the advice. And the result is that they do not have the condition that you and your GP were worried about.

Phew and double phew. You are really, really relieved – but for a year or so you were seriously worried.

The good news is that there is a way of doing away with that long period of worry.

Yesterday’s CIPFA/IfG report contained an example of how parts of the NHS are developing a system to cut through these months of unnecessary worry. It’s called an ‘Advice and Guidance’ discussion.

At one level this is very simple. The GP is not sure and asks for advice. The current system uses up chunks of the patient’s life waiting for months to find out whether they are right or not. The advice and guidance mechanism allows the GP to ask, over the phone, whether a patient should be referred.

This is not really a difficult thing to do – although of course with the NHS and any form of technology arranging for phone calls between doctors is problematic. (Someone will have to invent a phone that is personal to an individual that they can carry around. I’m sure it will happen soon).

But assuming we can get the technology to work and bring the two doctors together, this must be a good and a simple thing? It would mean that some patients wouldn’t have to go through months of worry before they know for sure.

And the really good news for most of us is that, since the pandemic, the numbers going through this system are increasing. And this may be responsible for the drop in the number of referrals as I mentioned yesterday.[1]

Since it was introduced in 2019 the number of requests for Advice and Guidance has risen from approximately 40,000 per month to more than 160,000 in March 2023. The target was set for GPs to use advice and guidance for 16 out of every 100 appointments. In fact, General Practice has exceeded that target – reaching 22 out of 100.

For most of these patients the referral will go ahead. For others, where the GP and the specialist agree that no referral is necessary, they will have avoided patients waiting months or years on elective waiting lists unnecessarily.

Interviewees also told the CIPFA/IfG report that GPs would almost always refer a patient to a specialist if they wanted to. After all, all this needs is a GP/patient conversation which says. “I’m not sure. I’d like a conversation with one of my colleagues to get their advice. Would you rather I did? “

But as always with any change in the NHS there are those that disagree.

The Royal College of GPs found out, in a survey of their members, that 64% of them believed that Advice and Guidance was being used to reduce the elective backlog in secondary care.[2]

Let’s just walk through that.

First of all, is it such a bad thing to have a policy and practice that actually leads to a reduction in waiting times for secondary care. Isn’t that what we want?

Second, given that the numbers using the advice and guidance system have risen so dramatically, if 64% of GPs really think it is such a bad thing, the 36% that are actually using it are obviously using it a lot.

Thirdly, since currently the GP is in fact referring the patient to the specialist, they are asking the specialist for their opinion. It’s just that presently they are using the patient as the mechanism for doing this whereas the new system uses a phone.

So, some are opposed.

Then, within a week of my reading the CIPFA /IfG report, the HSJ morning edition of the 17th November has the headline,

‘GP Advice services are becoming a barrier to good care.’

The headline is above an article by the Chair of the BMA GP Committee Dr Katie Bramall – Stainer.

“Not only does such bureaucratic inefficiency present an obvious danger to patients who clearly need an urgent specialist review it also adds unnecessary workload burden for GP’s struggling to keep their heads above water”.

Again, let’s unpack that paragraph.

The ‘obvious danger to patients who clearly need an urgent specialist review” surely arises from the fact that at the moment those patients are waiting a year for it.  Under the advice and guidance system if they are “patients who clearly need an urgent specialist review” they will be seen much more quickly if those patients who do notclearly need an urgent specialist review” are no longer in the waiting list.

The article ends by asking that we ‘focus on the patient at the heart of the pathway”. 

Yes, let’s do that. Let’s get GPs talking much more regularly to specialists, and by doing so let’s make sure that patients are not waiting for months with anxiety on a waiting list when they don’t need to be.

[1] The proportion of GP appointments that result in a referral has dropped 8.6% in 22/23 – less than 9.2 % in 2019/20

[2] Quoted in CIPFA and IfG op cit Page 69