I have recently gone back into general practice full-time. One thing that seems very clear to me is that it has become increasingly difficult to refer people into the hospital system unless they are critically ill. My last stint as a GP was in mid-2007, but, at that time, it seemed reasonably easy to refer a patient for a non-urgent problem. They might have waited many months just to see the specialist, of course, but at least they did not receive a letter informing them that “The hospital is unable to provide you with an appointment within the 6 month timeframe, so you are being transferred back to the care of your GP”. To which the GP (i.e. the MacDoctor) replies “If I could do anything for my patient myself, I wouldn’t have referred them to you, you pillock”.
My colleagues working in the area I was in in 2007 say that it has become more difficult for them as well, but I suspect much of the problem lies with the hopelessly understaffed (with doctors, not bureaucrats) Waitemata DHB (they of closed Waitakere Hospital ED fame). So far they have refused to see patients with mostly surgical problems which are not life-threatening (but are very debilitating). None of these were frivolous referrals and all need to see someone other than yours truly.
The aspect of this that really worries me is that these refusals are apparently done on the basis of obscure point-scoring systems that are assessed by lay people (or, possibly, junior doctors) without anyone beside myself ever seeing the patient in person. This means that they are completely reliant on my referral letter to contain all the information that they need. Unfortunately, at no point have they bothered to tell anyone what information they are looking for and their default position is to give the lowest score if the information is not there. This means that many referrals are very under scored and falsely rejected.
It is clear to me that this system is utterly hopeless. What needs to happen is that the scoring needs to be put into the hands of GPs – after all, it is the GP who the only doctor who has seen the patient. The score sheet and the referral should then be faxed to the hospital and the appointment booked the next working day for an appointment within the acceptable time frame for that score. The only reason why appointments are not made this way is because DHBs do not trust GPs to be honest in their assessments. The dysfunctional relationships between GPs and DHBs is longstanding and has not been improved by the DHB model, or the PHO one.
Under no circumstances should first specialist appointments be rationed. This appointment is the gateway into the rest of the hospital. If a first appointment is not made, I have no alternative but to tell my patients to try the emergency department (as this is the only other gateway available). Unfortunately, to get past the ED nurses (who often send chronic problems straight back to the GP), my patients have to wait until they experience a deterioration in their condition, which is about as far from ideal management as you can get. Suddenly a simple elective procedure becomes a major problem. People should not have to be dying to get into the hospital system.
This is a direct consequence of socialised medicine and it is why I get ratty when someone makes the silly comment “but at least even the poorest of us can get treatment” as a justification for it. No they can’t. Unless they have an acute illness or a potentially life or limb threatening problem, the uninsured amongst us are often denied treatment in the name of “triage” or “resources” or “points”. What is usually not explicitly stated is that this is simply rationing and that the poor, as usual, bear the brunt of it.