Referral management centres and diabetes
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Discussions on how to manage the interface betweengeneral and specialist practice are not new and were ventilated as long ago as 1998.1 Since then, sugges-tions from the Department of Health2 and other com-mentators3 have tried to find ways to limit the numberof patients being sent for an opinion and treatment atthe hospital. The null hypothesis has been that hospital based treatment is more expensive and there-fore a bad thing in principle. Referral managementcentres have appeared in increasing numbers, butnobody appears to know exactly where they are andsome are now changing their name to clinical assess-ment service. Most reports of their positive effectcome from organisations connected with theDepartment of Health.4 They have usually been set upwithout any consultation with GPs, specialists, orpatients. Their decisions to reject a referral are insult-ing to the GP, incomprehensible to the patient andfrustrating to the specialist.
Failure to seek advice appropriately is a GeneralMedical Council offence and it beggars belief that amanagement group is now being allowed to interferewith proper professional communications. That is whathas happened in orthopaedics and it has led to manypatients being denied the opinion of a specialist. Thatresults in unnecessary prolongation of pain from achronic disease which, though unpleasant, is not cata-strophic, but we are now hearing of this process beingapplied to neurological referrals. I have been trying todistinguish tension headache from raised intracranialpressure for 30 years. I usually get it right, but I amwrong sufficiently often to be very worried that a groupof dilettantes will misclassify serious disease. The samewill happen to our diabetic patients, where, for example,a patient with weight loss from a cancer of the pancreaswill be told that it is only their diabetes being a bit outof control.
Why have these centres been set up?There are two principal reasons, both political. First,referral to a specialist costs money, something thatthe primary care trusts dont have, despite their hav-ing sucked large amounts of it out of the hospitaltrusts. Second, if fewer referrals get through to thehospitals, waiting lists will shorten. These centres areintended to reduce the number of referrals by at least10% and to be fair, they are doing that. The argumentthat they are saving the specialists from seeing trivia,however, is specious and I have heard that the qualityof referrals has not improved as a consequence oftriage. There is also a risk that colleagues in generalpractice might adjust the history, in order to get pastthe screener.
How will triage affect GPs?When waiting times are shorter, our colleagues will beable to get patients seen more quickly. At presentthough, many diabetic clinics can see urgent cases in
the same week and often on the same day, while lesspressing problems seldom have to wait more thanfour weeks. It seems unlikely, therefore, that there willbe much improvement as a consequence of the addi-tional tier. GPs will be able to reflect on casesreturned to them and decide if these patients doneed to be seen and that could be safe, as long as theresource of a specialist on the end of the telephone isstill extant. That is one reason why it is so importantto preserve hospital based diabetes specialist services.The main disadvantage for GPs is that they will haveto explain to patients why their referral has beenbounced. That could be quite an embarrassing inter-view, because it implies that the doctor should haveknown better.
How will this affect specialists?It could mean fewer pointless referrals and perhapsimproved quality of letters. In my own practice, though,I dont often receive a completely unnecessary referraland most of the letters are perfectly satisfactory. True,the odd silly one does get through, but it doesnt takelong to reassure the patient and the GP that everythingis all right really and I believe that this facility is integralto a proper specialist service.
If we do accept filtering of referrals, we shall find itharder to train our specialist registrars. They have tosee patients with newly diagnosed type 2 diabetes, orminor diabetic complications, because otherwise theywill not gain the insight to tell when real problems arearising. If you like, its a way of learning the art of dia-betes care. As we all know, its not just science, butsince that concept cannot be quantified, it is impossi-ble to explain it to the educationalists that have hi-jacked the training of junior doctors.
How will our patients be affected?In a word, they will be bewildered. Consider the littleold man with a foot ulcer that wont heal. He has beentold that there are nice people at the hospital that willgive him special shoes and try to stop the ulcer gettingworse. At the same time, they will make sure that he ishaving the best possible treatment for his diabetes. Hewaits for six weeks and then receives a letter to say thathis GP will be able to deal with the problem. He thenhas to go back to his own doctor and make a newappointment, something which, with the pressure ongeneral practice, is becoming increasingly difficult toachieve within a week or two. When eventually he man-ages to see the right person at the surgery, he is toldthat the problem has got worse and that he must nowbe admitted as an emergency. He has thus been in dis-tress for nearly two months, during which time nothinghas happened and he now finds himself facing a possi-ble amputation. The referral centre, of course, willdeny any responsibility and, since the person whomade the decision is nameless, there is no hope of alegal remedy.
Pract Diab Int April 2007 Vol. 24 No. 3 Copyright 2007 John Wiley & Sons 119
Referral management centres and diabetes
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Are referral centres a good thing for patients with diabetes?The simple answer is no, but in order to prevent theirstarting to interfere with our patients, we shall have toadvance some convincing arguments. Some conditionscan be described in a short letter and orthopaedics is agood example of where that happens. It would, forexample, be clear if a woman has carpal tunnel syn-drome and how badly she was disabled as a result.Another example would be a patient who has had aheadache for three years, which makes the chances ofthere being a glioma pretty small. Both cases could bereferred back to their GP with reasonable confidencethat a specialist opinion was not essential. What aboutthe letter that says this diabetic patient is vomiting andI dont know why? That could easily be sent back by areferral centre, on the basis that vomiting is a trivialcomplaint and should be manageable in general prac-tice. The screener, however, has not considered the pos-sibility of there being a cancer and, of course, has nevereven heard of gastroparesis diabeticorum. With respon-sibility comes accountability, a concept that is unknownin administrative circles.
So what should doctors do?The options are to accept a fait accompli, try to changethe nature of the process, or involve the patients. Thefirst would mean that the bean counters had won. Thesecond might involve the referring doctors askingexactly who is conducting the triage and for details ofhow they had been trained. It would be reasonable toexpect that individuals should be named and for adetailed explanation to be given as to why a referral hadbeen returned. In my opinion, though, the third optionis best, as patient empowerment is highly esteemed bythe government. The GP should send a copy of thereferral letter to the patient, making it clear why a spe-cialists opinion is being sought. Then a copy of anycommunication from the referral centre, bearing thescreeners name, should be sent to the patient. If theywere unhappy, they would then know exactly who tocomplain to or about. The poor GP, who is blameless,would not be made to look foolish and the whole idioticsystem might collapse. This is one of those infrequentissues where both branches of the profession are inagreement. We should use it to our advantage tostrengthen ties between GPs and specialists.
Peter Daggett, MBBS, FRCP, Consultant Physician,Staffordshire General Hospital, Stafford, UK
References1. Rogers A, Entwistle V, Pencheon D. A patient led NHS:
managing demand at the interface between lay and pri-mary care. BMJ 1998; 313: 18161819.
2. Choose and Book: Patients choice of hospital and bookedappointment policy framework. Department of Health,2004.
3. Davies M, Elwyn G. Referral management centres: promis-ing innovations or Trojan horses? BMJ 2006; 332: 844847.
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