Referral from GPs to Referral from GPs to specialistsspecialists

Why do GPs Why do GPs refer refer

patients to patients to specialists?specialists?

General reasons for General reasons for referral by GPs to referral by GPs to

specialistsspecialists• To establish the diagnosisTo establish the diagnosis• For specific investigations (not For specific investigations (not

available in the community)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 Distribution of reasons for referralreferral

• DiagnosisDiagnosis 28%28%• Special investigation Special investigation 7%7%• Specific treatment or op.Specific treatment or op. 35%35%• Advice on managementAdvice on management 14%14%• Specialist managementSpecialist management

9%9%• Reassure GPReassure GP 2%2%• Reassure patient/ familyReassure patient/ family 2%2%• Other Other 2%2%

Devise referral criteria Devise referral criteria for a patient with for a patient with diabetesdiabetes

Issues to consider in Issues to consider in defining referral criteriadefining 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 Consider reasons for referral to a specialist in referral to a specialist in respect of specific chronic respect of specific chronic diseasesdiseases

Devise referral criteria Devise referral criteria for each chronic for each chronic diseasedisease

Referral rate by Referral rate by specialty (Ireland)specialty (Ireland)

Specialty Proportion of all referralsInternal medicine 29.7%Paediatrics 7.6%Dermatology 4.0%General surgery 15.2%Ophthalmology 5.9%Obs & Gynae 16%Psychiatry 3.2%

Referral rates for Referral rates for different European different European

countriescountriesCountry Referral rate

(per 1000 consultations)Ireland 42UK 47France 34Belgium 37Denmark 62-65Italy 66

Dangers of Dangers of over-over-

referral and referral and under-under-referralreferral

Dangers of Dangers of inappropriate or inappropriate or

excessive referralexcessive referral• Incorrect labellingIncorrect labelling• Collusion of anonymityCollusion of anonymity(Balint M. The Doctor, his Patient and the Illness)(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 Dangers of insufficient referralsreferrals

• Deprive patients of benefits of high-Deprive patients of benefits of high-tech medicinetech medicine

• Deterioration of patient’s condition - Deterioration of patient’s condition - perhaps to point where treatment perhaps to point where treatment becomesbecomes• more hazardousmore hazardous• less beneficialless beneficial• futilefutile

• Lose touch with medical developmentsLose touch with medical developments

What is an appropriate What is an appropriate referral?referral?

• Appropriate to whomAppropriate to whom• specialist specialist • 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 The GP as ‘gate-‘gate-

keeper’keeper’

Advantages of the GP Advantages of the GP gatekeeper system – for gatekeeper system – for

GPsGPs• it enables them to keep track of all it enables them to keep track of all

the patient’s problems and to be kept the patient’s problems and to be kept abreast of the patients conditions abreast of the patients conditions and their diagnosis and treatment. and their diagnosis and treatment.

• it is more satisfying for the GP to it is more satisfying for the GP to hold onto patients he or she can hold onto patients he or she can manage themselves manage themselves

• it is a stimulus to continuing it is a stimulus to continuing professional developmentprofessional development

Advantages of the GP Advantages of the GP gatekeeper system – for gatekeeper system – for

specialistsspecialists• it allows them to maintain their special it allows them to maintain their special

skills without having these diluted by skills without having these diluted by dealing with larger numbers of people dealing with larger numbers of people with little or no illness. with little or no illness.

• it ensures that his or her skills are used it ensures that his or her skills are used to best effectto best effect

• it avoids the specialist having to deal it avoids the specialist having to deal with other problems where he or she with other problems where he or she may be lacking expertisemay be lacking expertise

Advantages of the GP Advantages of the GP gatekeeper system – for gatekeeper system – for

patientspatients• it avoids the patient having to judge his or it avoids the patient having to judge his or

her own condition and decide if it requires a her own condition and decide if it requires a specialistspecialist

• it avoids having to choose which specialist it avoids having to choose which specialist to attendto attend

• it avoids the risks attendant on getting it avoids the risks attendant on getting either of these decisions wrongeither of these decisions wrong

• it may avoid undue expense (specialists it may avoid undue expense (specialists generally charge more than generalists generally charge more than generalists regardless of the nature of the problem regardless of the nature of the problem ultimately diagnosed.ultimately diagnosed.

Advantages of the GP Advantages of the GP gatekeeper system – for gatekeeper system – for the healthcare systemthe healthcare system

• it should lead to the most effective use it should lead to the most effective use of resources – both specialist and GPof resources – both specialist and GP

• it certainly helps contain healthcare it certainly helps contain healthcare costscosts

• it can lead to better health outcomes it can lead to better health outcomes overalloverall

Disadvantages of the GP Disadvantages of the GP gatekeeper system – for gatekeeper system – for

GPsGPs• it places all the responsibility for the it places all the responsibility for the

referral decisions on him or herreferral decisions on him or her• it may lead to him or her coming it may lead to him or her coming

under pressure from the health under pressure from the health payment system to restrict access payment system to restrict access to expensive specialist to expensive specialist

• it may lead to pressure from it may lead to pressure from patients to refer to specialists that patients to refer to specialists that the GP does not see as appropriate. the GP does not see as appropriate.

Disadvantages of the GP Disadvantages of the GP gatekeeper system – for gatekeeper system – for

specialistsspecialists• it may mean that patients whom it may mean that patients whom

he/she would like to see, possibly at he/she would like to see, possibly at an early stage of their illness may an early stage of their illness may not be seen because they have not not be seen because they have not made it past the GP gatekeeper made it past the GP gatekeeper

• it may be seen by some specialists it may be seen by some specialists as a restriction on their practice (or as a restriction on their practice (or earning capacity)earning capacity)

Disadvantages of the GP Disadvantages of the GP gatekeeper system – for gatekeeper system – for

patientspatients

• it can also be perceived as a it can also be perceived as a restriction on their choice of restriction on their choice of healthcare provisionhealthcare provision

• it can lead to worse outcomes if it can lead to worse outcomes if the gate is too restrictive the gate is too restrictive

Disadvantages of the GP Disadvantages of the GP gatekeeper system – for gatekeeper system – for the healthcare systemthe healthcare system

• it can negate the usual effects of it can negate the usual effects of market forces (and so both specialists market forces (and so both specialists and GPs may be able to charge the and GPs may be able to charge the system more for their servicessystem more for their services

• it can be more difficult to administerit can be more difficult to administer• it may be unpopular with patients it may be unpopular with patients

which will make it politically which will make it politically unattractive to a democratically unattractive to a democratically elected administrationelected administration

Contents of Contents of referral and referral and discharge discharge

lettersletters

Contents of the referral Contents of the referral letter - I (ideal)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 Contents of the referral letter - II (ideal)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 Any specific information/ service

needed from specialistneeded from specialist

Contents of the discharge Contents of the discharge letter (ideal)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 Information given to patient and/or

relativesrelatives• Follow up arrangementsFollow up arrangements• Advice of future managementAdvice of future management

Performance reviewPerformance review

• Referred patients an easily Referred patients an easily identifiable and important groupidentifiable and important group

• Cohort or case based review(s) Cohort or case based review(s) possiblepossible

• ? Interface audit - primary & ? Interface audit - primary & secondary caresecondary care

• Referral criteriaReferral criteria• Referral standardsReferral standards

Alternatives to referralAlternatives to referral

• Telephone consultationTelephone consultation• Domiciliary visitDomiciliary visit• Specialist outreach e.g liaison Specialist outreach e.g liaison

psychiatrypsychiatry• Joint consultationJoint consultation• Tele-medicineTele-medicine