Warnings follow new NHS referral rule reducing GPs’ autonomy

The RACGP says Australia can learn from new rules in the United Kingdom about the impacts of mandating referral advice, and continue to recognise GPs’ role in enabling continuity of care while maintaining clinical autonomy.
 
From 1 April the National Health System (NHS) has made it a fixed rule that GPs must seek advice from a consultant or senior clinician before referring patients, where it was previously optional.
 
Despite being embedded in the NHS for 10 years to give GPs the choice to seek advice from other specialists, the Advice and Guidance (A&G) system is now mandatory for all GPs to use before referring under their new NHS contracts, England’s Secretary of State for Health and Social Care Wes Streeting announced.
 
Established in 2015, the A&G digital service allows primary care clinicians to seek specialist advice before, instead of, or after referrals. The aim is to streamline care by reducing ‘unnecessary’ specialist appointments and referrals of patients to outpatient care. GPs were offered an extra $38 per use of the service.
 
Under the new mandate, GPs must submit queries with options to include clinical history, test results and images. A consultant or senior clinician then reviews the query, provides advice and recommends whether the patient should be referred, with the final decision made by the GP.
 
The NHS says it will cut unnecessary referrals to hospital specialists and see more patients referred to community-based care, but UK GPs are warning it could instead delay patient care and remove GPs’ autonomy.
 
The RACGP has previously warned of NHS ‘failings’ if other UK models were to be adopted in Australia, and while RACGP President Dr Michael Wright says the new A&G rule is not currently a threat, it can be used as an example of what would happen if GPs’ clinical autonomy is reduced.
 
‘What they’ve done here in this latest contract is said, “Before you can do the referral, you need to use that service”, and I’d be really concerned of putting extra barriers for people to access the care they need from a hospital service,’ he told newsGP.
 
‘And they may get extra waiting lists because they’re not acknowledging the expertise of a GP in making this referral.’
 
After completing his training in Australia, Dr Wright worked as a GP in the NHS, during which he found it ‘very hard’ to refer patients to other services, so he says the introduction of the A&G service was a ‘positive move’ in allowing GPs to get advice from other specialists.
 
‘For more than a decade, it has been quite a helpful process – but we just want to be careful of not adding extra barriers for patients and GPs, and shifting work on GPs to demand it in order to manage the workflow of the rest of the health system,’ he said.
 
‘We don’t have this system in Australia. GPs are recognised for their role in appropriately referring patients, and we just need to keep fighting for that on behalf of our patients as well as our profession.’
 
Meanwhile, Chair of the British Medical Association’s GP Committee, Dr Katie Bramall-Stainer, has raised concerns about the impacts on general practice of the new contract mandating A&G.
 
‘In last year’s contract it was an additional service ... now, taking away the right to refer means everyone’s going to be trapped in a doom loop in general practice,’ she said.
 
‘This genuinely is an existential threat to our existence, that we are critically endangered. We train to be GPs, we train to be expert medical generalists in the biopsychosocial model delivering holistic care to patients in our communities.’
 
While a national mandated advice system does not exist in Australia, components of A&G are integrated in some services, such as voluntary state-based referral hubs where administrators assess their requests.
 
Funded by the Queensland Government, the eConsultant Partnership Program enables GPs to seek advice from non-GP specialists at Mater Health.
 
Dr Wright also notes the Psychiatry Support Line for GPs, as a way to get additional advice when the GP might be uncertain about how to manage a patient.
 
‘These services are really helpful, but we’ve got to make sure they don’t become a way to add barriers which might make it harder for patients to get the care they need,’ he said.
 
‘Also, we need to make sure the expertise of a GP is recognised, as Australia has general practice referrals as a way to appropriately manage the use of hospital services and access to other specialists.
 
‘Through Medicare, GPs are recognised as the experts in ensuring patients receive appropriate referrals to the rest of the health system, and we just have to make sure we don’t get additional barriers that jeopardise that access for patients or make it harder for GPs to do our jobs with more red tape.’
 
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