Referral from GPs to specialists

Why do GPs refer patients to specialists?

General reasons for referral by GPs to specialists To establish the diagnosisTo establish the diagnosis For specific investigations (not available in the community)For specific investigations (not available in the community) For specific treatment or operationFor specific treatment or operation For advice on managementFor advice on management For specialist to take over managementFor specialist to take over management To reassure the GPTo reassure the GP To reassure the patient/ relativesTo reassure the patient/ relatives

Distribution of reasons for referral Diagnosis28%Diagnosis28% Special investigation 7%Special investigation 7% Specific treatment or op.35%Specific treatment or op.35% Advice on management14%Advice on management14% Specialist management9%Specialist management9% Reassure GP2%Reassure GP2% Reassure patient/ family2%Reassure patient/ family2% Other 2%Other 2%

Devise referral criteria for a patient with diabetes

Issues to consider in defining referral criteria DiagnosisDiagnosis Special tests – fundoscopySpecial tests – fundoscopy Development of complicationsDevelopment of complications NeuropathyNeuropathy Renal diseaseRenal disease Retinopathy treatmentRetinopathy treatment Poor controlPoor control Commencement of insulin therapy??Commencement of insulin therapy??

Consider reasons for referral to a specialist in respect of specific chronic diseases Devise referral criteria for each chronic disease

Referral rate by specialty (Ireland)

Referral rates for different European countries

Dangers of over-referral and under- referral

Dangers of inappropriate or excessive referral Incorrect labellingIncorrect labelling Collusion of anonymityCollusion of anonymity (Balint M. The Doctor, his Patient and the Illness) Somatic fixationSomatic fixation Deskilling of the GPDeskilling of the GP Deskilling of the specialistDeskilling of the specialist

Dangers of insufficient referrals Deprive patients of benefits of high-tech medicineDeprive patients of benefits of high-tech medicine Deterioration of patient’s condition - perhaps to point where treatment becomesDeterioration of patient’s condition - perhaps to point where treatment becomes more hazardousmore hazardous less beneficialless beneficial futilefutile Lose touch with medical developmentsLose touch with medical developments

What is an appropriate referral? Appropriate to whomAppropriate to whom specialistspecialist GPGP patientpatient What will be gainedWhat will be gained health gainhealth gain prevention of health lossprevention of health loss social gainsocial gain

The GP as ‘gate-keeper’

Advantages of the GP gatekeeper system – for GPs it enables them to keep track of all the patient’s problems and to be kept abreast of the patients conditions and their diagnosis and treatment.it enables them to keep track of all the patient’s problems and to be kept abreast of the patients conditions and their diagnosis and treatment. it is more satisfying for the GP to hold onto patients he or she can manage themselvesit is more satisfying for the GP to hold onto patients he or she can manage themselves it is a stimulus to continuing professional developmentit is a stimulus to continuing professional development

Advantages of the GP gatekeeper system – for specialists it allows them to maintain their special skills without having these diluted by dealing with larger numbers of people with little or no illness.it allows them to maintain their special skills without having these diluted by dealing with larger numbers of people with little or no illness. it ensures that his or her skills are used to best effectit ensures that his or her skills are used to best effect it avoids the specialist having to deal with other problems where he or she may be lacking expertiseit avoids the specialist having to deal with other problems where he or she may be lacking expertise

Advantages of the GP gatekeeper system – for patients it avoids the patient having to judge his or her own condition and decide if it requires a specialistit avoids the patient having to judge his or her own condition and decide if it requires a specialist it avoids having to choose which specialist to attendit avoids having to choose which specialist to attend it avoids the risks attendant on getting either of these decisions wrongit avoids the risks attendant on getting either of these decisions wrong it may avoid undue expense (specialists generally charge more than generalists regardless of the nature of the problem ultimately diagnosed.it may avoid undue expense (specialists generally charge more than generalists regardless of the nature of the problem ultimately diagnosed.

Advantages of the GP gatekeeper system – for the healthcare system it should lead to the most effective use of resources – both specialist and GPit should lead to the most effective use of resources – both specialist and GP it certainly helps contain healthcare costsit certainly helps contain healthcare costs it can lead to better health outcomes overallit can lead to better health outcomes overall

Disadvantages of the GP gatekeeper system – for GPs it places all the responsibility for the referral decisions on him or herit places all the responsibility for the referral decisions on him or her it may lead to him or her coming under pressure from the health payment system to restrict access to expensive specialistit may lead to him or her coming under pressure from the health payment system to restrict access to expensive specialist it may lead to pressure from patients to refer to specialists that the GP does not see as appropriate.it may lead to pressure from patients to refer to specialists that the GP does not see as appropriate.

Disadvantages of the GP gatekeeper system – for specialists it may mean that patients whom he/she would like to see, possibly at an early stage of their illness may not be seen because they have not made it past the GP gatekeeperit may mean that patients whom he/she would like to see, possibly at an early stage of their illness may not be seen because they have not made it past the GP gatekeeper it may be seen by some specialists as a restriction on their practice (or earning capacity)it may be seen by some specialists as a restriction on their practice (or earning capacity)

Disadvantages of the GP gatekeeper system – for patients it can also be perceived as a restriction on their choice of healthcare provisionit can also be perceived as a restriction on their choice of healthcare provision it can lead to worse outcomes if the gate is too restrictiveit can lead to worse outcomes if the gate is too restrictive

Disadvantages of the GP gatekeeper system – for the healthcare system it can negate the usual effects of market forces (and so both specialists and GPs may be able to charge the system more for their servicesit can negate the usual effects of market forces (and so both specialists and GPs may be able to charge the system more for their services it can be more difficult to administerit can be more difficult to administer it may be unpopular with patients which will make it politically unattractive to a democratically elected administrationit may be unpopular with patients which will make it politically unattractive to a democratically elected administration

Contents of referral and discharge letters

Contents of the referral letter - I (ideal) Name, address, dob(age) of patientName, address, dob(age) of patient Presenting complaint/ problemPresenting complaint/ problem History of presenting complaintHistory of presenting complaint Past medical historyPast medical history Current (& ? Past) medication(s)Current (& ? Past) medication(s) Allergies (if any)Allergies (if any) Social history (relevant - esp. carers)Social history (relevant - esp. carers)

Contents of the referral letter - II (ideal) Findings on examinationFindings on examination Results of any investigationsResults of any investigations Your opinion of problem/ diagnosisYour opinion of problem/ diagnosis Reason for referralReason for referral Any specific information/ service needed from specialistAny specific information/ service needed from specialist

Contents of the discharge letter (ideal) Summary of symptomsSummary of symptoms Examination findingsExamination findings Results of investigationsResults of investigations Diagnosis or summary of problem(s)Diagnosis or summary of problem(s) Management planManagement plan Nature and quantity of drugs issuedNature and quantity of drugs issued Information given to patient and/or relativesInformation given to patient and/or relatives Follow up arrangementsFollow up arrangements Advice of future managementAdvice of future management

Performance review Referred patients an easily identifiable and important groupReferred patients an easily identifiable and important group Cohort or case based review(s) possibleCohort or case based review(s) possible ? Interface audit - primary & secondary care? Interface audit - primary & secondary care Referral criteriaReferral criteria Referral standardsReferral standards

Alternatives to referral Telephone consultationTelephone consultation Domiciliary visitDomiciliary visit Specialist outreach e.g liaison psychiatrySpecialist outreach e.g liaison psychiatry Joint consultationJoint consultation Tele-medicineTele-medicine