I'm not navigating the cross-referral maze

One of the less attractive aspects of the purchaser-provider split is the ham-fisted way in which primary care organisations try to save money by controlling referrals.

We have already experienced the stupidity of targets for cutting emergency admissions: 'Which patient with chest pain should I refrain from admitting?' Now, time for phase two: minimising cross-referrals in hospitals.

There is good and bad here. It is irritating and insulting when a hospital doctor cross-refers a patient to another consultant for a disease that GPs can deal with in our sleep - such as uncomplicated hypertension.

But now the pendulum has swung to the opposite extreme. Our PCT has issued an edict: except in dire emergency all cross-referrals have to go via the GP. What a waste of time.

In the past three weeks, I've had a child with a significant finger injury sent back from casualty with instructions for me to refer her to the hand clinic in the same hospital; I've been asked to refer a patient attending the orthopaedic department with a knee problem to a back specialist in the same department because the knee pain may have a back component; and perhaps most ridiculous of all, a man referred to plastic surgery for one skin lesion was sent back for re-referral to the same department for a second lesion at a different site.

My involvement as a GP in each of these incidents was bureaucratically-driven and unnecessary: each patient needs the second specialist's opinion. The PCT's protocol makes the referral chain longer, creates unnecessary delays, inconveniences the patient, risks introducing clerical errors, takes up the precious time of the GP, and - as organising a referral costs about £50 in staff time and an appointment to discuss it - puts an unnecessary strain on hard-pressed primary care.

As an experienced GP, I don't take kindly to being treated as a glorified clerk. Professionally, the solution is easy: permit the PCT to allow internal referrals, but insist that these are all approved by consultants, rather than instigated by juniors. But there is another more profound way, involving the psychology of NHS organisation and management. More on this next week.

Dr Lancelot is a GP from Lancashire. Email him at GPcolumnists@haymarket.com 

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