Transcript GP 4001 Lecture 8 Referral from GPs to specialists

Referral from GPs to specialists
Why do GPs
refer patients
to specialists?
General reasons for referral
by GPs to specialists
• To establish the diagnosis
• For specific investigations (not available
in the community)
• For specific treatment or operation
• For advice on management
• For specialist to take over management
• To reassure the GP
• To reassure the patient/ relatives
Distribution of reasons for
referral
• Diagnosis
• Special investigation
• Specific treatment or op.
• Advice on management
• Specialist management
• Reassure GP
• Reassure patient/ family
• Other
28%
7%
35%
14%
9%
2%
2%
2%
Devise referral criteria for
a patient with diabetes
Issues to consider in defining
referral criteria
• Diagnosis
• Special tests – fundoscopy
• Development of complications
• Neuropathy
• Renal disease
• Retinopathy treatment
• Poor control
• 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)
Specialty
Internal medicine
Paediatrics
Dermatology
General surgery
Ophthalmology
Obs & Gynae
Psychiatry
Proportion of all referrals
29.7%
7.6%
4.0%
15.2%
5.9%
16%
3.2%
Referral rates for different
European countries
Country
Ireland
UK
France
Belgium
Denmark
Italy
Referral rate
(per 1000 consultations)
42
47
34
37
62-65
66
Dangers of
over-referral
and underreferral
Dangers of inappropriate or
excessive referral
• Incorrect labelling
• Collusion of anonymity
(Balint M. The Doctor, his Patient and the Illness)
• Somatic fixation
• Deskilling of the GP
• Deskilling of the specialist
Dangers of insufficient
referrals
• Deprive patients of benefits of high-tech
medicine
• Deterioration of patient’s condition perhaps to point where treatment
becomes
• more hazardous
• less beneficial
• futile
• Lose touch with medical developments
What is an appropriate
referral?
• Appropriate to whom
• specialist
• GP
• patient
• What will be gained
• health gain
• prevention of health loss
• social 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 is more satisfying for the GP to hold
onto patients he or she can manage
themselves
• it 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 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 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
specialist
• it avoids having to choose which specialist to
attend
• it 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.
Advantages of the GP
gatekeeper system – for the
healthcare system
• it should lead to the most effective use
of resources – both specialist and GP
• it certainly helps contain healthcare
costs
• it 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 her
• it 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.
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 gatekeeper
• 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 provision
• it 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 services
• it can be more difficult to administer
• it 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 patient
• Presenting complaint/ problem
• History of presenting complaint
• Past medical history
• Current (& ? Past) medication(s)
• Allergies (if any)
• Social history (relevant - esp. carers)
Contents of the referral letter
- II (ideal)
• Findings on examination
• Results of any investigations
• Your opinion of problem/ diagnosis
• Reason for referral
• Any specific information/ service
needed from specialist
Contents of the discharge letter
(ideal)
•
•
•
•
•
•
•
•
•
Summary of symptoms
Examination findings
Results of investigations
Diagnosis or summary of problem(s)
Management plan
Nature and quantity of drugs issued
Information given to patient and/or relatives
Follow up arrangements
Advice of future management
Performance review
• Referred patients an easily identifiable
and important group
• Cohort or case based review(s) possible
• ? Interface audit - primary & secondary
care
• Referral criteria
• Referral standards
Alternatives to referral
• Telephone consultation
• Domiciliary visit
• Specialist outreach e.g liaison
psychiatry
• Joint consultation
• Tele-medicine