This blog was written in response to this BMJ Head to Head debate on whether GPs should be paid to reduce unnecessary referrals.
As someone living with long-term health conditions, I want the NHS to be both ethical and financially sustainable. It shouldn’t be that those two characteristics are mutually exclusive.
As a self-management coach for the NHS working with people with long-term health conditions, I often see people desperate for a referral or fed up with too many different referrals. Those two sentiments aren’t necessarily mutually exclusive either.
My interest in this topic lies not with the processes that seem to be driving the arguments, but about the conversations that happen between GPs and their patients and how referrals are discussed and decided upon.
When I have wanted another referral, or I listen to people that I work with, our stories have hope, expectations and personal health beliefs woven through it. “someone must know what is going on with my body”
“they must be able to find out what is causing the pain, and do something about it”
The shared decision making conversation that may or may not end with a GP making a referral should explore these hopes, expectations and personal health beliefs. Once we understand the health beliefs that someone has and their hopes, a full picture of possible solutions can be explored; of which referral to secondary care may be one. The rise of social prescribing is a form of referral that is being actively encouraged, to voluntary and community services and support[i]. This isn’t a substitute for clinical referrals, but can support GPs to meet the expectations and hopes of their patients without making unnecessary clinical referrals.
If a referral is made, as is often appropriate, the conversation should focus on how to make that next conversation between the patient and another healthcare professional as effective as possible. Aside from integrated clinical notes, this is about supported agenda setting for example[ii]. We can’t and shouldn’t avoid referrals, but we should aim to make them as useful as possible for patient and professional alike.
The carrots or sticks of financial links and the ethical reasoning both focus on changing behaviours, but have we clarified what skills clinicians need to fulfill these behaviours? At the end of the day, its all about conversations rather than processes. We may be giving our GPs the financial and ethical arguments, but on a practice basis, when faced with a patient in clinic with hopes and beliefs, are we giving them the skills to share decision making with patients to make the most appropriate referrals?
[i] More than Medicine, NESTA, 2013 (https://www.nesta.org.uk/sites/default/files/more_than_medicine.pdf)
[ii] Your Appointment Plan leaflet, NHS Ayrshire & Arran (http://personcentredcare.health.org.uk/resources/outpatient-agenda-setting-sheet-respiratory-medicine-0)