A frequent topic at meetings where the different eye care professions are represented is the quality of referrals from optical practice to general practitioners and secondary care. It is something that is raised by GPs and ophthalmologists alike and not in a complimentary manner, thus creating a constant source of tension for optometry with their professional counterparts. The general quality of referrals is viewed as poor as the perception is that there are too many patients directed towards their GP or hospital, only to find there is no further investigation and/or treatment required. While some may take the view that it is better to ‘err on the safe side’, and so this is not an issue, consider the wider implications of this scenario.
Firstly, referring to a GP for an opinion is a dubious route for us to take, unless it is with a specific instruction as to what action we expect of the GP. The GP does not have the equipment for further investigation and often not the skills and knowledge required. Talking recently to a GP colleague, the rumoured brevity of their training regarding eyes is actually reality. At least to the GP there is no additional cost involved, other than GP time, however, if the patient visits secondary care, whether through the GP or goes direct to hospital, there is a cost to the NHS of around £120 for the appointment.
The true cost however, in my opinion, is the lost trust in the optometric profession. The patient will lose trust in the expertise of their optometrist as they have had unnecessary worry while waiting for their appointment, only to find that there is no further action required. If the optometrist has got this wrong, at what else are they not proficient? At the unnecessary hospital appointment all too frequently ophthalmologists are not slow in telling the patient they thought this was a poor referral and are critical of the optometrist, further reducing patient trust. To cap it all the general reputation of the profession is reduced in the minds of ophthalmologists and GPs. The capability of the whole profession is taken from a view of the lowest common denominator. This is not conducive with our efforts to be more involved in eye care, such as enhanced schemes in the community. If we are unable to manage straightforward patients, will we be able to manage more complex patients?
Some may consider this scenario of poor referrals only applies to a very few cases. However, I believe it is actually more commonplace than is thought and there is a small but significant minority adversely affecting our reputation. Something needs to be done.
There will be a variety of reasons behind poor referrals. The system we operate in, where the NHS pays a paltry fee for a sight test, certainly does not encourage any practitioner to go that little bit further and decide what the best outcome for the patient should be. There will be practitioners where there is a lack of knowledge and understanding of a patient’s signs and symptoms and ultimately what is wrong with them. This uncertainty may lead the practitioner to blindly refer, recognising something is different, but not really knowing what. Alternatively, they may suspect they know what the condition is, but do not have the confidence to take responsibility and need the second opinion. In other practices there may not be time to do that little bit extra as there is pressure to see numbers, patients are waiting and a referral is the easiest option.
Clearly something needs to change, despite the fact there are practitioners who actively take the view that we should do what we are paid for and no more, almost to the point of over-referring to make the point – not a course of action I would support.
There may be no easy answers. Education for practitioners will be important and perhaps the best form of this would be feedback from the secondary sector to the referring practitioner with the outcome of the referral. One can only learn from good and also poor referrals. A more radical approach would be for optometric advisers to actively follow up practitioners or practices where there is a poor record of false referrals. Could some form of penalty be enforceable through any part of the NHS contract?
Many areas have amended referral forms to direct the referring practitioners to think more about why they are referring. These should become the norm. There are schemes in place around the country where referrals are triaged and while these are in some ways putting a sticking plaster over the problem, ultimately they do save money and are to be encouraged.
There is a lot that can be done, but the key point will be for each practitioner to have self-awareness of their referral history, how it compares to their peers and actively find out what the outcomes have been. Without this how do you know whether you are achieving good clinical outcomes?