Referrals from hospital sector to GPs (and vice versa)

Vorsprung

Would be interested to hear from both sides of the fence on this one.

Most of my time to date has been in hospital medicine, so I really only have one side of the story. I have often been guilty of blasting some GPs for "inappropriately" referring some patients to EDs, but I've only recently come to realise the full extent of cuts to services they have access to. I don't think this explains all the referrals I've blasted I hasten to add. I've no doubt the some GPs have got letters from me in the past and said "why doesn't he organise his own ****ing <insert investigation here>!".

What got me thinking about this was a comment from a Meath GP in the Irish Medical News in an article on pretty savage cuts to the NEDOC budget:

Dr Séamus McMenamin, Chairman of NEDOC, said that, “pressure on day and out-of-hours GP services is growing as doctors are faced with increasing numbers of inappropriate referrals to their surgery and to NEDOC from the hospital sector.

So here's the questions - what constitutes an inappopriate referral from the hospital sector to a GP? And given the resources as they stand now, what strategies can be put in place to reduce these instances?

his_dudeness

There are plenty of situations, particularly in a surgical OPD, where a "non-surgical" issue will crop up in the discussion, and instead of doing the sensible thing and referring onwards or even investigating ourselves, there is an ethos of "send it back to the GP and let them sort it out" - not every consultant but definitely some of them.

Can be frustrating as a junior when its something you know how to manage but the bosses "won't" let you

sam34

in relation to the above, iirc, the medical council recommend that individual specialists refer back to the gp for issues outside their area, rather than sorting it themselves (if something fairly straightforward) or making a referral to another consultant. they advocate that the gp should be overseeing or coordinating everything. it creates extra work certainly, but I suppose at least there's one person who knows exactly what's happening, what's been done, what's pending etc.

Xeyn

Exactly. The GP should almost always be the primary doctor for any patient. There is less chance of a Chinese whisper problem where information is lost if the GP coordinates these issues.

When I worked in a busy Dublin A&E through a surgical scheme it was hospital policy that all patients had to be referred back to their GP to arrange specialist OPD appointments if they did not warrant review at presentation. A&E staff were not allowed to refer patients to OPD for any speciality within the same hospital that they worked in. It sounds odd and it created problems but there is no way round once it's policy.

Working in a breast cancer centre, we were told that GPs as a group are not happy to do follow up care for patients who have reached 5 years post surgery and all clear. Yearly follow up usually involves a breast examination and looking at a MMG report. So now what happens to the breast clinics which are already far too dangerously over prescribed (170 patients to get through in one day for 3-4 doctors) With no cancer patients being discharged ever the system will collapse.

Both the GP services and the public health services are overburdened and each to some extent are guilty of trying to get the other to take some of their own burden.

Vorsprung

Working in a breast cancer centre, we were told that GPs as a group are not happy to do follow up care for patients who have reached 5 years post surgery and all clear.
[\quote]

Not happy ever or not happy without training? I know the GP contract issue has stalled a lot of the chronic disease management stuff so that might be another issue.

I know a lot of bosses I've had wouldnt be happy for me to treat certain things or do procedures that they're not happy to stand over, which is fair enough I think for the reasons stated above.

Xeyn

To be perfectly honest I'm not clear about the exact reasons. It was relayed to us by one of the consultants at a meeting.
I'd imagine it might be a litigation issue although that's conjecture on my part.
My dads a GP in Dublin and there are services that have been cut to the bone so far as to actually cost the GPs to treat. I don't blame GPs for refusing to do things when it comes to that.
What it will mean is more pressure on the HSE hospitals and will ultimately cost the government more. Some of the decisions being made beggars belief.

I was told that if you're an A&E doctor for 6 months and you don't know certain GPs In the referral area that means they are good GPs.

Every field ends up bitching about the other. Anaesthetics vs surgeons, medics vs surgeons, A&E vs medics, A&E vs GPs vice versa etc ad infinitum.
Every group feel they are right. It's sad but having worked in a few continents its the same everywhere.

RobFowl

Xeyn wrote: »

To be perfectly honest I'm not clear about the exact reasons. It was relayed to us by one of the consultants at a meeting.
I'd imagine it might be a litigation issue although that's conjecture on my part.
My dads a GP in Dublin and there are services that have been cut to the bone so far as to actually cost the GPs to treat. I don't blame GPs for refusing to do things when it comes to that.
What it will mean is more pressure on the HSE hospitals and will ultimately cost the government more. Some of the decisions being made beggars belief.

It's mainly because the logistics cost money. Settting up call/recall systems referring for mammograms, yearly consults, following up non attenders.
All this costs money and the proposal was to simply transfer the work without any additional resources.
As GP's we're sick to the teeth of this and this proposal was the final straw at a time when GP funding has been but by 32-40% (as apposed to 20% in general for the HSE).

sam34

Rob, can I ask about psych referrals. genuine question, I'm not trying to set you up.

I often get referrals along the lines of "this man has asked to see you" - to me, that's totally inappropriate. if I walked into a gp and said I'd like to see a neurologist, I'd expect to be asked why, and exam +/- tests done before a referral is made. the same doesn't seem to apply to psych, at least in my sector. I know the fault is partly mine, in that I accept the referrals, but the reason I accept them is just time really- if I write back saying I need further info, the gp will send that in and then I'll see the patient, so I may as well just see them after the initial crap referral.

but I do wonder, would they send such crap referrals to other specialists. I can't imagine a cardiologist or surgeon tolerating that.

I know I'm making massive generalisations, but do you think there's a lower threshold for psych referrals than others?

RobFowl

sam34 wrote: »

Rob, can I ask about psych referrals. genuine question, I'm not trying to set you up.

I often get referrals along the lines of "this man has asked to see you" - to me, that's totally inappropriate. if I walked into a gp and said I'd like to see a neurologist, I'd expect to be asked why, and exam +/- tests done before a referral is made. the same doesn't seem to apply to psych, at least in my sector. I know the fault is partly mine, in that I accept the referrals, but the reason I accept them is just time really- if I write back saying I need further info, the gp will send that in and then I'll see the patient, so I may as well just see them after the initial crap referral.

but I do wonder, would they send such crap referrals to other specialists. I can't imagine a cardiologist or surgeon tolerating that.

I know I'm making massive generalisations, but do you think there's a lower threshold for psych referrals than others?

Some GP's have a higher thresehold for referrals. There are some stupid situations eg insurance companies refusing to insure some one who has had mild depression without a psych opinion. I am uncomfortable with some of the GP training here (purely my opinion) as I know you can become a GP without AE or psych experience which IMO is absolutely nessecary.
That said i've ben guilty of caving into patients incessant demands to see specialists.
I fear in psych as you tend not to see much private practice it ends up in the public system whereas a lot of the other demands are often seen privately.
Where I work we have a councellor and really try to manage all but the dangerously suicidal and psychotic at GP level.
Not too sure where you'd stand but I'd view almost all depressive/anxiety disorders as treatable in GP but psychotic illness is not something I think we can manage well.


Edit; referring someone just because they ask without a proper exam and history is intirely inappropriate.

Vorsprung

RobFowl wrote: »

...I know you can become a GP without AE or psych experience which IMO is absolutely nessecary....

(Off topic) What scheme is that?

RobFowl

Vorsprung wrote: »

(Off topic) What scheme is that?

Quite a lot of them !

sam34

RobFowl wrote: »

Some GP's have a higher thresehold for referrals. There are some stupid situations eg insurance companies refusing to insure some one who has had mild depression without a psych opinion. I am uncomfortable with some of the GP training here (purely my opinion) as I know you can become a GP without AE or psych experience which IMO is absolutely nessecary.
That said i've ben guilty of caving into patients incessant demands to see specialists.
I fear in psych as you tend not to see much private practice it ends up in the public system whereas a lot of the other demands are often seen privately.
Where I work we have a councellor and really try to manage all but the dangerously suicidal and psychotic at GP level.
Not too sure where you'd stand but I'd view almost all depressive/anxiety disorders as treatable in GP but psychotic illness is not something I think we can manage well.


Edit; referring someone just because they ask without a proper exam and history is intirely inappropriate.

in my sector, there seems to be a culture of referring everyone at the drop of a hat. as I said, maybe I'm partly to blame for perpetuating that, but it was there long before my time. most of my referrals are straightforward anxiety, depression, grief, life issues etc. I long for the psychotics and manics!

I do sometimes wonder about taking a stand and sending back the referrals, but I think that'll only waste time and create bad feeling with the GPs, nearly all of whom I get on well with.

it's frustrating though- my routine waiting list is 3-4 weeks, and I work damn hard to keep it at that. if some of the unnecessary referrals were weeded out, I could reduce that to maybe two weeks and also look at doing some assessments on a domiciliary basis.

Xeyn

RobFowl wrote: »

It's mainly because the logistics cost money. Settting up call/recall systems referring for mammograms, yearly consults, following up non attenders.
All this costs money and the proposal was to simply transfer the work without any additional resources.
As GP's we're sick to the teeth of this and this proposal was the final straw at a time when GP funding has been but by 32-40% (as apposed to 20% in general for the HSE).

Do you know what the HSE reply was to the very understandable refusal?
Again the HSE's decisions are just making more work for one group or another. In this case I'm sure it would cost less to set up a system with a fail safe to keep these patients in a follow up loop with their GPs than to offer nothing and have GPs refuse to do their (HSE's) work and thusly costing the HSE even more money to keep them in the public system.

OMD

sam34 wrote: »

in my sector, there seems to be a culture of referring everyone at the drop of a hat. as I said, maybe I'm partly to blame for perpetuating that, but it was there long before my time. most of my referrals are straightforward anxiety, depression, grief, life issues etc. I long for the psychotics and manics!
.

After you see them though do you then immediately discharge them for GP follow up? If not then the referral would essentially be appropriate. In other words if you don't discharge after the single visit you are saying that your expert medical opinion as a psychiatrist is that this patient is unsuitable for follow up by GP alone and requires the services of a psychiatrist.

sam34

yes, if I think they're suitable for gp care. you'd think that'd gradually get the message across, but sadly, no.

MrCreosote

sam34 wrote: »

I often get referrals along the lines of "this man has asked to see you" - to me, that's totally inappropriate.

I'd imagine
"this man has asked to see you"= I don't think there's anything important vs
"I would like you to see this man"= there's something I'm worried about.

Maybe I'm reading between the lines too much?