For most of my NHS career patients have had an automatic right of a referral to hospital outpatients or of an admission to a hospital ward. GPs use this privilege carefully as we all understand that the NHS service is a limited resource paid for by taxpayers and is for our community, to be shared on the basis of need not want or demand.

GPs would traditionally have referred about 5% of the patients they saw in their surgery to hospital outpatients for further investigation and advice. Only 1% require direct admission. These referrals were never questioned, but this has radically deteriorated with many referrals now refused for a variety of reasons and about 27% of referrals in some areas of the UK are sent back without the patient getting an appointment for outpatients. One of the most common reasons is “doesn’t fit the criteria for this service.“

This is very frustrating for the patient as if they want seen they will probably have to pay to go privately. If this sounds like I’m criticising my hospital colleagues I’m not because this change has been introduced by managers trying to manage waiting lists in an overwhelmed, collapsing service.

The situation for direct admissions to hospital wards is much worse as this service has now collapsed to the point where it doesn’t seem to exist at all for many specialities. If I had a patient in the past with a serious exacerbation of their heart, lung, ENT or surgical systems I would have talked to the specialty and had the patient admitted directly to the ward. This rarely happens now and GPs are advised to send patients directly to the emergency department (Casualty) for assessment. As a result Casualty is overwhelmed then despite the best efforts of the staff there and my older patients with previous experience would rather take their chances at home.

placeholder image — Derry GP Dr Tom Black.

Just in case anyone thinks I am exaggerating the situation, the health watchdog HSSIB has linked the recent changes in outpatient referrals in England to patient deaths and the Royal College of Emergency Medicine have told us repeatedly that the present crisis in ED has resulted in increased mortality rates for patients.

So what should patients do if they go to their GP with a problem which results in a referral to hospital, which is refused? There isn’t a single answer to that question. I’ve had recent cases of referrals refused where I thought the patient was at a significant risk of cancer and I’ve discussed the case directly with the consultant and an appointment was allocated and cancer was found. This however is time-consuming and stressful for all concerned. In other cases I chat to the patient and tell them that the waiting list for the service refused is so long they would be wise to go privately and generally the patients will do this if they can afford to. Unfortunately, some of the patients refused an outpatient appointment or an admission deteriorate and have no alternative but to go to Casualty and sit in the queue there.

It's no wonder that no one wants a job as a GP in Northern Ireland because it is so difficult to help patients in a system where the referrals to hospital are blocked.