The pros and cons of self-referral on the NHS

Patients should be allowed to bypass their family doctor to make self-referrals to specialists, said Keir Starmer.

Speaking to the BBC, the Labour leader said he wanted to “lift the burden” on the NHS by allowing more patients to contact specialists directly, “so that individuals don’t have to go to a doctor, use up a doctor’s time in order to get referred to specialist help.

“If you’ve got back pain and you want to see a physio it should be possible, I think, to self-refer,” he added. “If you’ve got internal bleeding and you just want a test, there ought to be a way that doesn’t involve going to see a GP.”

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Speaking on LBC, Starmer clarified that self-referral for bleeding “would only apply for people seeing blood in their stool and needing a test for which GPs routinely referred them”, said The Times. He said getting the test without seeing a GP first was “an example” and “all of this will be subject to discussion with the professionals of course as to what would work”.

But he insisted: “We’ve got so many examples of going to a GP and then being referred elsewhere and there are examples where we think we can cut that down.”

The interview has caused a stir in political and medical circles. Here are the arguments for and against self-referral.

1. Pro: faster treatment

Self-referral “cuts waiting times” and faster access to specialist care “helps prevent acute problems from becoming chronic and reduces long term pain and disability”, wrote Karen Middleton for Health Service Journal.

During a trial in Torbay, a self-referral mode saw waiting times cut from ten weeks to less than three days for more than 90% of patients, she said.

Middleton, chief executive of the Chartered Society of Physiotherapy, felt that the pressure on the health service make these advantages ever more timely. “When GPs are under such enormous pressure, when patients are waiting longer for an appointment, when budgets are becoming ever tighter, the time for self-referral is surely now,” she said.

2. Con: potential dangers

Starmer’s example of someone with internal bleeding has raised wider concerns about the safety of self-referral. “Hopefully, we don’t need to state the bleeding obvious (pun very much intended) as to why this is utter nonsense,” said indy100.

Experts have also criticised the proposal. “As a health professional, if you’ve got or think you have internal bleeding bypass your GP and phone an ambulance,” tweeted Jon Squires, a nurse specialist in palliative care.

“For Keir Starmer to advocate self-referrals for internal bleeding is a recipe for disaster that will waste resources and cost lives,” the Socialist Health Association, Labour’s affiliated socialist society for healthcare and medical professionals, told The Guardian.

3. Pro: mental health support

Self-referral can be beneficial for those seeking help for mental health problems, according to a study.

People “may feel embarrassed” about discussing their problems with the family doctor, or “fear that they will be seen as weak and/or unable to cope”. They “may also have concerns that there is insufficient time to talk about problems”, found a study published in the British Journal of General Practice.

Also, the researchers concluded, many people “believe that their GP would not be able to offer treatments other than antidepressant medication, which is commonly regarded with suspicion”.

4. Con: encourages ‘Dr Google’

After Starmer’s interview, concerns were raised that the move could encourage people to self-diagnose online. “There is a real danger people would turn to Dr Google and inundate specialists with referrals for illnesses they don’t have,” Dennis Reed, from Silver Voices, which campaigns for elderly patients, told the Daily Mail.

Writing for the BMJ, Helen Salisbury, a GP, cited Starmer’s example of having a lump on the back of his head and needing to see a dermatologist. “How did he know that he needed a dermatologist, rather than an oncologist or an ENT specialist,” she asked, “or maybe some blood tests, an ultrasound scan, antibiotics, or just reassurance?”

5. Pro: saves money

Self-referral could free up more time for GPs, which saves funds. Up to 30% of patients seeking a GP consultation do so with a musculoskeletal complaint, such as back or neck pain, wrote Middleton, meaning more than 100 million appointments could be freed up in England alone if patients were given the choice of a physiotherapist as their first contact.

With that additional capacity comes “significant savings”, she added, and “health economist modelling” showed it “cut costs by £33 per patient, which equates to a saving of up to a quarter”.

6. Con: bad for GP morale

There is concern that self-referrals could undermine the standing and morale of GPs. Advocates for self-referral misunderstand “the role of the GP”, wrote Jaimie Kaffash, editor of Pulse.

Describing the GP as “the gatekeeper”, he said “their role is to manage undifferentiated symptoms; it is telling the difference between the harmless and the harmful rash”.

Dr Rachel Clarke, a doctor and writer on the NHS, dismissed the proposal as “monumentally stupid (& insulting) on multiple levels”, reported GB News. The “dismissal of the role of GP as a bureaucratic waste of time” betrays “spectacular ignorance of how healthcare works”, she tweeted.