I have noticed on Facebook a number of issues about patient concerns about getting referrals. In this blog I have tried to explain the “rules“ that GPs have to follow and also different approaches that GPs and patients can take.

GPs are paid by the NHS and have a contract with them to provide services to patients. Within the contract are essential services which must be provided. In simple terms they are:

1. Manage patients who are or believe themselves to be ill, this includes acute illnesses, chronic illnesses, and terminal ones. This should be delivered in the manner determined by the contractor’s practice in discussion with the patient.
2. Provide appropriate ongoing treatment, including giving advice and referrals.
3. For the purpose of management, they should offer a consultation and where appropriate physical examination in order to identify the need for treatment, further tests, or referral.

The full contract is available below and the relevant part is 8.1 which is page 47 of 239 pages!

https://www.england.nhs.uk/wp-content/uploads/2022/11/B1990i-standard-general-medical-services-contract-november-2022.pdf

I have looked through this and a number of official documents to be able to reference a few of my statements but can’t find the relevant documentation. I think this is partly as some documents are legal ones, they are all long and the contract keeps being changed. I can’t find one simple document. These statements were correct when I was working both as a GP and a CCG Cancer Lead. I don’t think things have changed in the 2 years since I retired.

The contract you have with your GP used to be with individual doctors. It is now with the practice.  This means that in general you can see any GP in the practice (although all the evidence is that continuity of care from a GP you have confidence in is best for both patient and GP).

When the GP does a referral, they should provide all the information to the hospital that is needed.

GPs are required to not waste NHS money that includes unnecessary tests, referrals, and prescribing.

If a GP does or doesn’t refer you it makes no financial difference to a GP.

As well as referrals most GPs have access to “advice and guidance”. A service where they can present a problem to the hospital consultants and get advice about appropriate action. This can be a very efficient service for a GP to get a second opinion from an expert. In most areas this is encouraged as a very efficient use of resources. In many cases the hospital will ask to see the patient, in others they may advise the GP to arrange some tests or treatment.

For many conditions GPs are now required to follow local guidelines. A common example is indigestion type symptoms without any worrying signs that would otherwise warrant an urgent 2 week wait cancer referral. GP's may be required to follow a series of tests or treatments before a referral. In some cases, the hospitals are told to reject any referrals that do not meet the required guidelines or threshold.

The NHS has recognised that a GP’s gut feeling and patient concern can sometimes mean that referral is indicated outside guidelines. It is up to the GP to argue why that is the case in their referral letter.

Second opinions in general practice are generally easy as you are registered with a practice not a GP. It is rarely appropriate to try and get a second opinion through an out of hours (OOH) GP service unless something acutely changes when the surgery is closed. My experience was that patients rarely get a useful response if they go down the OOH route.

If you live within the catchment area of another practice, you can change GP without giving a reason. I would always recommend explaining the reason to your new GP.

A second opinion from a hospital is not a right. This is what the Macmillan website says.  Asking for a second opinion is not a legal right, but most doctors will be happy to refer you. If you are unsure about anything to do with your diagnosis or treatment, you can always ask for another appointment with your GP or consultant.

The contract is specific in how decisions are made “This should be delivered in the manner determined by the contractor’s practice in discussion with the patient”