"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Sunday, 8 July 2012

Self referral

"I haven't seen you for years, your condition must be bad: I only get to see the difficult cases."

This is what the consultant eye surgeon said to me at an emergency appointment at the eye clinic early in the summer of 2005. He was right, the last time I had appointment with him was seven years before. When I moved to the area I was referred to the hospital for diabetic retinopathy by my previous doctor. Retinopathy is a condition where the blood vessels on the retina grow large and weak and are liable to burst. Previously I had had a big bleed in one eye and had started a series of laser treatment. This treatment continued under the new consultant, having many thousands of laser burns per eye (a session every 3 months, then 6 months over a period of 5 years). I was referred to the eye surgeon's clinic and initially it was him that treated me, then when my eyes stablised another doctor from his team took over the treatment. In the follow up for my last treatment by the senior consultant he told me that there was one blood vessel that they could not treat and I should expect it to burst some time. Now I was in his office with the results of when that vessel bursting.

The previous few days I had removed about a tonne of hardcore from my garden. Over several years I had dug up stones and concrete in my garden and I wanted to get rid of this pile. I ordered a skip and spent a couple of days moving the hardcore from the pile to the skip. This involved a lot of bending down and picking up heavy stones. The next morning I noticed a strange mark on my retina and remembering the previous bleed, I went to my optician. He looked at my retina and told me to go immediately to the hospital eye clinic. I was fitted onto the list of one of the doctors and, after seeing my eye, he made an appointment the following week for the senior eye surgeon. And that is when he made the comment above.

The seriousness of the bleed made me a priority. Indeed, the bleed was so large that the surgeon called in two of the other doctors in the clinic to see the extent of the bleed and compare it to the photos of the vessel that had burst. There was an impromptu case meeting. The surgeon told me that I would need an operation under general anaesthetic where the gel in my eye (the vitreous humour) would be removed and then he would stop the bleeding of the vessel and clean up my retina. My eye would then be re-filled with an oil-like substance which my body would eventually absorb (over a period of about a month) and replace with more of the vitreous humour. The size of my bleed made me a priority for surgery and the surgeon's list was changed accordingly.

The surgery was successful, and the surgeon was able to clean up some of the damage from the previous bleed, so I had eyesight that was better than it had been for a decade. There is still some permanent damage and this is like having several blind spots in my eye. After the surgery I had a follow up with the eye surgeon and although I have had several follow up appointments for my retinopathy, I didn't see him again until I needed cataract surgery, which he also carried out.

The government has decided that in the interests of "patient choice" we all must have the choice of the "consultant-led team" for our care. This is an attempt to get closer to the US system of patient referrals. Self referrals are one of the causes of the high costs of the US system. If an American colleague gets a rash they will go and see "their" dermatologist. If I get a rash I will see my GP and if my GP thinks the rash needs the opinion of someone more specialist, I will be referred to the consultant dermatologist. The NHS system ensures that you get care according to need. It is the GP who decides what that need is: can they deal with it, or does it need a specialist. This is NHS prioritising, which some people call "rationing", but it is rationing only in the sense that GPs "ration" the work of the specialists to only those who need it. I have had countless arguments with American colleagues who interpret NHS prioritising as a form of denial of care. It isn't. The NHS ideal is that we get the care prioritised according to our clinical need. Those who do not get the care, do not need it.

Diabetic retinopathy cannot be "cured", so I still have 6 monthly monitoring of my retinas. If I was given the choice of consultant I would choose the eye surgeon who had operated on my eyes. I like his manner and how he explains my condition to me. But I also know that he is considered the best eye surgeon in the region. When it comes to their health, everyone wants the best. Every surgeon's time is limited, so he limits his time to the more serious conditions. My eyes are stable, so I will be a waste of his time and expertise. That is the way that the NHS works and it means that regardless of who you are or what you earn, if you need the expertise of the top clinician in the country, you will get it.

In the US the rationing of expertise is carried out through money: only those with the most amount of money can afford the best. In the NHS the "rationing" is carried out according to clinical need. 

Lansley's plan of choice of "consultant-led team" will be a failure. The guidance says:
"Patients who want to should be able to choose a particular named consultant-led team for their first consultant-led outpatient appointment where it is clinically appropriate. The right to access services within maximum waiting times under the NHS Constitution continues and applies to patients who choose to be referred to a named consultant-led team."

The 18 week referral to treatment waiting time target means that the more popular consultants (inevitably the most skilled) cannot handle the increased numbers of patients through longer waiting times. The only tool they have is the interpretation of the terms "consultant-led team" and "clinically appropriate". This policy will fail to give the patients the consultant they demand because responsible consultants will interpret "consultant-led team" to mean that they can delegate a patient to another doctor who is part of their team. They will also interpret "clinically appropriate" as I have outlined above: the consultant will see the higher priority cases and his junior staff will see the rest.

Lansley does not expect this policy to succeed because he knows that it cannot succeed. However, even as a failure this policy will achieve what Lansley wants: it will increase patient demand for self-referral, and that will lead us to a healthcare system that will be worse for us because we will not get the care we need, and it will lead to a system that most of us cannot afford.


  1. Good explanation.

    What most of the dishonest critics of the NHS fail to acknowledge is that ALL healthcare systems have some form of 'rationing.' It's all a matter of how.

    As far as I can see there are essentially 2 options

    1. Need
    2. Ability to pay

    I have no doubts which is right and which is wrong.

    Oh, and worth noting that seeing a non-consultant in clinic is not a sub-standard service also. I know this, because as a junior I know that whatever encounters I have with patients are supervised by my consultant. Cases are discussed all the time and they establish how to approach various clinical scenarios.


  2. Excellent explanation, and all the better for being personal. The idea that everyone can have the best, whatever that may be is clearly nonsense. My only quibble is that best doctors may not be the most popular. Harold Shipman was very popular.

  3. Good point Martin. And that leads to the concerning issue of what happens if an FT finds that the consultant they have employed at £100k has no patients because they are not "popular". Will this lead to consultant self promotion? Will we find that skilled, but brusque clinicians will be given their P45?

  4. It's late finding this act. At least, it's a thing to be familiar with that there are such events exist. I agree with your Blog and I will be back to inspect it more in the future so please keep up your act. bybit referral code