We have to reduce our referrals, they declared. It's essential and if we don't, there will be dire consequences. This is all very well, but who should I refuse to admit? That man with the chest pain? The woman with the acute abdomen which might be appendicitis (but then again, might not)?
It's easy for non-clinical managers to talk this way - but what if things go wrong? Who will take the blame, pay the compensation or appear before the GMC?
I don't send patients in unnecessarily. I refer them only where secondary care alone possesses the specialised equipment, expertise or staff to deal with the situation. For a non-clinical manager to insist that I reduce my referrals is insulting to my professional abilities and an incitement to negligence. The nub of the problem is that coercing GPs presents no risk to managers.
If they are lucky, nothing too dreadful happens. Referral rates and costs go down and the manager looks good. If a patient dies or is harmed, 'the failure to refer is clearly the clinical responsibility of the doctor'. The GP will undoubtedly be perceived as the villain, however managerially pressured they may have felt beforehand.
Bearing in mind that power without responsibility is a recipe for organisational disaster, the balance needs redressing. If NHS managers want to strong-arm GPs into reducing referrals by 15 per cent, fine - but it should be the primary care organisation or consortium that takes the risk, shoulders the blame, faces the press and pays compensation, rather than letting GPs' reputations founder and their medical defence subscriptions rise, as they undoubtedly will otherwise.
NHS managers must be held responsible for mistakes made by 'their' GPs when under pressure from on high; if there are too many patient complaints about non-referral, the manager involved should be disciplined or even sacked. Direct accountability like this might affect a sea-change in the attitude of NHS managers to clinical care - and not before time, either.