General practice plays a central role in ensuring patients receive a timely and accurate diagnosis, either directly from a GP or from an appropriate specialist as a consequence of a GP referral. Failure, or delay, in correctly identifying and referring patients who need secondary care can have profound clinical consequences.
Related document: The quality of diagnosis and referral
What did we explore?
To inform its work, the Inquiry panel commissioned a research project to examine what good-quality diagnosis and referral by general practice looks like, and how it can be measured. The quality of GP diagnosis and referral looks at variations across general practice, and identifies evidence-based ways to improve the quality of this core aspect of GP care. The paper is written by a team from The King's Fund: Catherine Foot, Chris Naylor and Candace Imison.
What have we learnt about diagnosis and referral?
In March 2010 the Inquiry held a seminar on diagnosis and referral with participants including GPs, practice nurses, NHS executives, health academics and patient representatives.
Key issues raised in discussion include:
- Has the introduction of the 'Choose and Book' referral process undermined the relationships between GPs and individual hospital consultants, to the detriment of patient care?
- How might judgements be made about what degree of variation in diagnosis and referral ought to be deemed acceptable, and therefore at what level any quality indicator thresholds ought to be set?
- Are the growing number of clinical guidelines mitigating against their utility in general practice?
What's your view?
During the inquiry, we asked for your opinions on this care dimension. You can read the comments submitted below.
Also, GPSIs have been found to make more referrals in their field of expertise than other GPs.
Could it be that we are under-referring much of the time?
The competing demand is not between providing primary care and gatekeeping, but between being charged with making (comprehensive = all inclusive) care available against the non-contractual expectation that access to secondary care should be rationed / that GPs have a responsibility to guard resources.
Contractually GPs are obliged to make referrals, not doing so could be a breach of contract. The judgement would lie on the prospective benefits of a referral. Telling a patient their condition cannot be helped saves writing a letter and several appointments as patients will not come back after seeing secondary care or return after a failed treatment. Some GPs may be more inclined to explore more avenues before turning the patient down and/or offer the same options to affluent and deprived patients. The motives for this might relate to GP workload and income rather than being sensitive to patient demand and belief about the benefit of referral. There is an inherent conflict of interest in the UK system as more use of primary care resources means fewer patients can be serviced, which means lower capitation income. Cream skimming and compromises on quality are two ways to increase income in a capitation remunerated health care system.
"The activity around the first two dimensions of the quality of diagnosis (gathering sufficient evidence and information, and judging the evidence and information correctly) takes place largely within a consultation. It would therefore seem necessary to measure and assess doctors’ skills and behaviours in consultations as part of their continuing professional training and assessment."
I agree. However I do not agree to the proposed methods of assessment. The only way to assess real time performance is to routinely review consultations. One way of doing this would be covert random checks through NHS net, with remote access of a desktop camera and audio, another through standardised patients (mystery shoppers). The latter has limitations and cannot normally cover complex patient presentations or situations. Your proposals of audit and PROMs will not suffice, it has been shown that there is little relation between patient questionnaires and standards judged by trained observers posing as patients. (annfammed.org/cgi/content/full/5/2/151)
The QOF is a P4P program that rewards data collection and does not cover the dimensions that define the core activities of communicating, diagnosing and managing patients.
Looking at outcomes through audit will also miss these aspects of care as the presentation of serious disease in primary care is so low that missing or ignoring patient cues does not normally affect health outcomes. Because of the low incidence of adverse outcomes in primary care and the low volume of serious conditions, it is possible to run unsafe systems or have unsafe practice for many years without direct consequences.