Report questioning value of GP referrals draws RACGP fire

Doug Hendrie

29/09/2020 4:26:11 PM

The college has pushed back against claims that many GP referrals to specialists represent ‘opportunistic rather than purposeful clinical engagement’.

GP giving patient a referral.
GP referrals have been vigorously defended.

The comments formed part of a wider piece in The Conversation Australian Healthcare and Hospitals Association researchers, who questioned the ‘wasted dollars’ in a ‘broken referral system’ and suggested referral terms can be too short.
‘The “gatekeeper” role of GPs in patient care is reinforced by legislation framing the referral system. However, GP engagement through referral expiration is a model that is based on opportunistic rather than purposeful clinical engagement,’ the researchers note in the full report.
‘Improving information sharing among service providers through real-time health information exchange would avoid the need for low-value administratively driven GP consultations, and address any ongoing concerns by GPs regarding the impact of expanded referral pathways and periods of referral validity on continuity and coordination of care.’
RACGP Acting President Associate Professor Ayman Shenouda told newsGP the argument shows a ‘lack of understanding’ of the valuable role GPs played in the health system. He said the core function of general practice is to see patients first – due to the wide range of knowledge possessed by GPs – and only refer if necessary.
‘People in hospitals have little understanding about what actually happens in general practice and the value and function of it,’ he said.
‘General practice does play a facilitation role, but its core function is a lot wider than that. GPs have skills to analyse and deal with the majority of conditions patients are facing.
‘The majority of health needs are addressed by GPs.’
Associate Professor Shenouda said the decision to treat or refer is an important part of general practice.
‘We screen the population for health issues and refer as required depending on severity or rarity,’ he said.  
‘In terms of follow-up of patients, GPs are skilled in following up current treatments in all fields of medicine.’
In a response on Twitter, RACGP President-elect Dr Karen Price criticised the piece for a lack of insight into general practice.
‘[GPs] provide the majority of diagnostic skills across all the specialties and a significant amount of ongoing care. GPs are specialists in chronic complex multimorbidity where the patient’s care is not fragmented into disease boxes by multiple referrals,’ she wrote.
‘Extended referrals from specialists are a bad idea. I have many patients attending six or seven different specialists all for very much general practice care that I provide for other patients.
‘No, they do not need to see an endocrinologist subspecialising in bone every six months simply for a Denosumab injection. No, [patients with] chronic kidney disease that is stable [do] not need to see a renal specialist every six months. On and on [goes] the waste of Medicare dollars and patients’ time.’
Dr Price said primary care has many challenges, including a ‘chronically underfunded patient payment system’ that has resulted in some cases in high volume care.
‘The churn and burn … needs to be reviewed if it is the case and type of practice to which the authors unwittingly seem to refer,’ she wrote.
‘There are many better ways to ensure patients are well looked after in our complex health system, but diminishing the role of the specialist general practitioner and diminishing the power of generalism as a healthcare philosophy is a dangerous road to take for both health economics, patient care and population health outcomes.’
Responding to Dr Price on The Conversation website, co-author Samantha Prime said her response highlights important issues such as a lack of inter-professional communication.
‘The article does not advocate undermining the role of the GP – simply using GPs more effectively,’ Ms Prime wrote.
‘Given how important communication is in healthcare, we should really look to a system of enhanced interoperability that does not rely on “referrals” as a mode of keeping GPs informed.’
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Dr Arshad Hussain Merchant   30/09/2020 7:08:28 AM

GP role are undermined by everyone including the college itself. Your value $35/= . No one look at the poor quality hospital and specialist care. When was the last time any specialist investigated for demanding on hospital discharge letter for private referral to their clinics. When you explain the inappropriateness and refusal to comply with demand, here starts a painful complaint process. GPs are not GATE KEEPER, they are SPECIALIST in their field so STOP treating them as a gate keeper

Dr Gaurav Tewary   30/09/2020 9:51:22 AM

Let’s all move to this ‘enhanced info sharing’ model.

GPs will state all day long at computer screens and download/upload info to My health. Their dashboards will ping every time one their patients attends a specialist, allied health professional, noctor, phoctor or quack.
They will peruse this info in their own free time for the benefit of their patients. Don’t you know GP medication records are woefully inadequate when it comes to RACF patients?

Of course the GP won’t get paid for this because hey, they aren’t actually seeing the patient when they do all this. That is for other more ‘important’ people to do.

No, Ms Prime you’re not devaluing general practice at all.

Dr Abdul Ahad Khan   30/09/2020 10:17:52 AM

Yet one more Assault by GP Bashers !!!

Dr. Karen Price's Comments are spot on.

There are many many many instances, wherein I initially seek an Opinion from a Specialist & then I manage the Patient myself very competently for years & years - without the need to keep seeing the initially referred Specialist ad infinitum.

GPs are HIGHLY TRAINED & are HIGHLY COMPETENT in the full wide Spectrum of Family Practice - no surprise that Australia leads the World in the Quality of Primary Care.

Yes Dr. Merchant, our Medicare Rebates are Pathetic.
Yes Dr. Merchant, we are Specialists in Primary Care.
The ' Gate-keeper ' Role though, is very apt & is very much needed.
The Patient must not continue to keep seeing Specialists ad infinitum.

It is ONLY & STRICTLY ONLY, when the management of our Patient is beyond our Ability, that an Input from a Specialist becomes necessary.
Without us GPs, the Cost of Health Care will sky-Rocket !

These GP Bashers are SIMPLY IGNORANT .

Dr Primo Phillip Bentivegna   30/09/2020 11:31:49 AM

"Responding to Dr Price on The Conversation website, co-author Samantha Prime said her response highlights important issues such as a lack of inter-professional communication."
Who is Samantha Prime? What is her training and experience in General Practice?
How exactly did she draw her her conclusions based on Dr Price's comments, who by the way is a practicing GP of many years?
Clearly Ms Prime has no idea about how General Practice works, and is in no position to comment on the referral process let alone the inter-professional communication between specialist GP's and their non-GP specialist colleagues.

Dr Isaac   30/09/2020 1:37:39 PM

The problem here is poor quality referrals from some doctors .. this is a fact and we have to agree about this. Example " I refer to you for further assessment .." what does this mean ? what are the symptoms ? what is the main concern to refer to specialist or hospital OPC ? ... then another problem is some patients asking for referral while you have not met them before and if you dont refer them, they will get into a cheap doctor to do it or you can face a complaint and you waste your time to defend yourself !! so the whole saga is consumer rights more than providing quality medical knowledge. So we are dealing with consumers and products not medicine .... and who created this problem.... its AHPRA , because we have few lay people working there with some doctors sitting there to keep their revenues wink ..
Another issue the poor quality doctors carrying fellowship from RACGP, this is another fact ,.. RACGP must tighten it fellowship to the right doctors who can treat not refer!

Dr Peter James Strickland   30/09/2020 1:41:36 PM

Having been in GP practice over a period of 40 plus years there are positives and negatives about referrals to specialists. Good specialists refer their referred patients back to their GP, and not decide to manage everything by inter-referring to their specialist colleagues --yes, the latter happens often! Patient not being able to have ongoing MBS treatment because of a 12 month referral rule is straight from bureaucrats (oncology for cancers is an example). The best specialists keep in touch by phone or email to their GP colleagues on recommended treatments, and want the GP to be part of the treatment -- that is good medicine. The RACGP have to fix pathetic fee rebates for specialist GPs for the same treatments or consultations of OTHER specialists!

Dr Janice Faye Sheringham   30/09/2020 5:07:39 PM

Dr Strickland, as a Life Member and Fellow of RACGP, I take serious issue with your final sentence - just HOW ON EARTH do you expect RACGP to “ fix pathetic fee rebates”??? In the words of Ms Hanson, PLEASE EXPLAIN! Just what do you imagine both GP organisations have been trying to do, along with the AMA, ever since the differential rebates were introduced? Keep up with medical politics sir, or drop such useless rubbish comments! Rant over.

Dr Jitendra Natverlal Parikh   3/10/2020 10:07:24 AM

I think we have to accept the fact that
1 at least 50 % of referral are given at patient's request and we do not have a choice
2 And if you do not do it some of your colleague will
3 I always write in my letter clearly that it is at patient's request which hopefully someone should notice
4 whenever the above issue pops in the quality of reasoning goes down for which we are blame
5 There are ofcourse the optometrists breathing down your neck issuing referrals to ophthalmologist behind your back
6 I acknowledge the reasoning behind majority of referral is poor due to poor thinking and note keeping
I hope we all need to make an attempt to write why we are referring

Dr Henry Arthur Berenson   3/10/2020 10:38:05 AM

GPs are not the gatekeepers. Triage is. It allows selection based on profit over need.