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)
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