The Guardian view on Labour’s plans for selfreferral: approach with caution
It’s a story that most people in England are familiar with: you ring the GP to book an appointment and are put on hold, only to be informed 20 minutes later that all the slots that day have been taken. Many people are struggling to book GP appointments and therefore waiting longer to be referred to specialist clinics. Satisfaction with GP services has fallen sharply, and the market for private appointments is growing.
Labour plans to allow more patients to bypass GPs and refer themselves to specialists. For those with “red flag” cancer symptoms, who could otherwise be waiting weeks to see a family doctor, this could be an improvement. Research suggests that survival rates for cancer patients are lower in health systems that adopt a “gatekeeping” system of GP referrals. A screening app or digital checklist could filter patients with a breast lump, for example, and allow them to skip this step. People can already refer themselves to a sexual health clinic, and NHS England is planning to expand this for services where GP involvement is not “clinically necessary”, such as hearing aids and podiatry.
Extending this further should be approached with caution. Many people now Google their ailments, but information is no substitute for expertise. GPs have holistic knowledge and can spot things that patients cannot see. The NHS has operated a gatekeeping model since it was founded in 1948, which keeps health costs down and ensures that only those who need specialist treatment receive it. There is a risk that patients who are already disadvantaged, or who don’t speak English as a first language, would be less likely to use a self-referral system, entrenching the “inverse care law” identified by the GP Julian Tudor Hart, where those who most need healthcare are least likely to get it. “Overtreatment” – where people have medical care they do not need – is also a risk to health. This is widespread in the US, where patients can see consultants without a referral.
On average, general practitioners see a million patients a day in England, of whom about 3% are referred to a specialist. Currently, 7 million people are waiting for consultant-led treatment, and increasing numbers are waiting more than two months to start cancer treatment after an urgent GP referral. Even a small increase in the number of people referring themselves to specialists would create further delays. Existing backlogs are caused by shortages of staff and equipment. Nurses and doctors are leaving the NHS due to dire working conditions and low pay, while austerity has shrunk hospital capacity. The numbers of MRI units and CT scanners per capita in the UK are among the lowest in the Organisation for Economic Co-operation and Development. Opening the gates in an already strained system is unlikely to lead to patients being seen quicker.
One way of improving health outcomes and patient satisfaction would be to ensure that people could more easily see a GP. The main reason for delayed appointments is the shrinking number of family doctors. In 2020, the government promised to recruit an additional 6,000 by 2022, yet England has lost almost 2,000 qualified full-time GPs since 2015. A depleted workforce is left to deal with an ageing and unwell population, with some GPs now taking as many as 90 consultations each day. Only 7% of health spending goes on primary care, and a national public health strategy remains a distant prospect. So long as this continues, expanding self-referral would heap pressure on a system in crisis.