Referral management schemes pose a serious threat to patients' interests

Referral management schemes pose a serious threat to patients' interests, argues Peter Lapsley, Chief Executive of the Skin Care Campaign, in this week's British Medical Journal.

Referral management schemes are springing up across the NHS as a means of reducing primary care trusts' spending on secondary care services.

The justification given for the introduction of the schemes is that they bring services "closer to home" - a mantra repeated often by the government at present. But trust managers admit privately that the true purpose of the schemes is to reduce costs in the face of the budget deficits so many of them are confronting, he says.

Typically, such schemes require that 80% of GPs' referral letters be reviewed in primary care and that 60% of cases should be retained within the trust. In many cases GPs are being offered financial incentives to participate in the schemes.

Lapsley firmly believes that these schemes pose a serious threat to patients' interests. They introduce an extra step in the patient's journey, delaying the diagnosis and treatment of often complex and difficult diseases, he writes.

What is more alarming is that some primary care trusts now deliberately delay outpatient appointments, refusing to fund routine paper referrals seen within eight weeks of the date of the referral letter. In contrast, patients who can be booked into clinics directly through the Choose and Book electronic booking service can be seen within two to three weeks, no matter what their complaint.

The schemes also remove any vestige of "patient choice," another government mantra, he adds.

In the case of dermatology, about 15% of GPs' consultations in Britain relate to skin disorders, yet the average undergraduate curriculum has only six days of dermatology, and only 20% of GP vocational training schemes include a dermatological component. Practice nurses receive no such training.

Referral management schemes therefore create a real risk that patients with skin diseases will be seen by clinicians who lack the necessary training and experience, greatly reducing the likelihood of prompt and accurate diagnosis, not least in respect of skin cancer, he argues.

The schemes are also insulting to GPs, second guessing their decisions. They undermine the viability of secondary care dermatology, and they remove any incentive for secondary care specialists to support or develop the role of the GP with a special interest in dermatology.

The schemes may provide a short term solution to a short term financial problem. The risk, though, is that they will do lasting damage, he concludes.