What happens (in UK) When a GP refers me to a specialist?
In the UK state funded healthcare is rationed. The amount of money spent on Healthcare is allocated by the treasury to the Department of Health which then allocates the money to the NHS which then calculates how much money should be allocated to each Clinical Commissioning Group (CCGs). CCGs are largely based in primary care, but some specialist services have their own national level Specialist Commissioning Groups. This is because some conditions are sufficiently rare no “local” group would be able to devote sufficient funding or develop enough experience to enable them to appropriately resource and make informed decisions with regard to rare or unusual conditions. CCGs all have a legal duty to provide (or purchase) certain core services for the population they serve, they also have a duty to provide services in line with the relevant directives from the National Institute for Health and Care Excellence (NICE). This is the basis upon which hospitals and other providers are then asked to provide services which the CCG pay for.
In the UK’s NHS there are 3 kinds of referral, routine, urgent and “suspected cancer” (otherwise known as 2 week wait or HSC). Once a referral is received it is usually reviewed by a clinically qualified individual, often a consultant but may be a specialist nurse or specialist trainee in some institutions. The person will then decide whether the patient should go straight to an investigation (such as an endoscopy) or be seen in clinic. At this stage the priority set by the GP will be reviewed. It is possible for the hospital team to alter the priority. To change the patient priority is straightforward for urgent and routine referrals but the process is much more cumbersome for those referred with suspected cancer.
Usually patients triaged to endoscopy will receive an appointment within a couple of months, or a couple of weeks if they have suspected cancer. For those triaged to clinic, suspected cancer referrals will be seen quickly, usually within two weeks and the hospital incurs a penalty for no doing so (though is not allowed to charge a premium for seeing more patients on time!) routine or urgent referrals may take weeks or sometimes months to be seen. This is because clinic capacity frequently does not allow for timely review. In part this may reflect the funding of UK Healthcare system, but in part it may reflect inherent inefficiencies within the conventional ways clinic and our healthcare systems are organised.
Although it is possible to change the priority of those patients referred by their GP as “suspected cancer” even when it is clear the patient does not have cancer it is often easier to simply see the patient than to go through the arduous process of changing the priority. It should be emphasised that the vast majority (usually about 95%) of patients referred on the suspected cancer pathway do not have cancer. Sadly most patients who are diagnosed with cancer are referred on a routine pathway. In most patients with a cancer the biggest delay in diagnosis of cancer is usually the time from onset of symptoms to referral to hospital rather than the inherent delays in being seen once the referral has been made. Nevertheless we could always do better.
If patients choose to see a doctor privately they can either pay via an insurance company or to the doctor directly. Paying doctors directly enables rapid access at relatively less cost than paying for annual insurance; usually an outpatient appointment alone runs to a one to two hundred pounds, but the “on costs” are often very significant. Blood tests, scans and procedures in the UK often cost thousands of pounds if undertaken on a self-pay basis, so ask about the costs before agreeing to such investigations. Unless people have considerable disposable income they should consider carefully whether undertaking extensive investigations privately confer significant advantage over the “NHS route”. Insurance companies are usually happy to cover the initial cost of investigation but policies may exclude or significantly increase the costs if the policy is to cover longstanding disease.
If I pay privately or I am insured how should I chose a gastroenterologist, or any other specialist for that matter?
Firstly you should try and see someone who is interested in the complaint from which you suffer. Not all gastroenterologists share the same interests. For example I (Dr Smale) am a luminal gastroenterologist, so my interests are definitely not in the liver! My particular interests are in functional gastro-enterology (like IBS), the microbiome and helping patients with making better choices. Whilst there is a standard of care which you can expect from all accredited gastroenterologists, for example most of us are capable endoscopists and colonoscopists, some gastroenterologists have particular interests and skills. If I have patients with Hepatitis I would advise them they are better to see a hepatologist, similarly if they have complex pancreatic disease or stones within their bile duct they are better seeing one of my colleagues with the skills to undertake ERCP, which I no longer possess.
Secondly it is worth asking how do I know this doctor is as good as they say they are? All of us have some data on our performance in relation to the care we deliver. Endoscopy related data is usually the best curated of these and it may be worth asking about their recent data. One of the challenges with this is that the way different hospitals collect data is exceedingly variable. Many institutions say their clinicians get good outcomes, this is often based on flawed data collection and perhaps it might be honest to say “we have no evidence of bad outcomes”. The attribution of data (such as that related to operations or mortality) may be flawed and significantly distort the performance of an individual clinician. For example I have in the past had operations attributed to me which I have no idea how to perform and have never even watched let alone undertaken. Another factor is that clinicians who are really good and see high volumes of cases often get referred the more difficult cases which confer a higher risk of complication and mortality and this is not always picked up when the data is presented.
Thirdly if a clinician is proposing an invasive investigation or treatment, for which he or she is being paid it is worth asking what are the benefits of this (potentially expensive and uncomfortable) procedure for me? How will it help manage my symptoms or risks? It is very easy for clinicians to do more, because they can, particularly when they are being paid to do so. Whilst the great majority of doctors have utmost integrity it is of note that in healthcare systems where doctors are paid per test or procedure, as opposed to per diagnosis or as a block contract, they tend to do more tests and procedures. This may have benefits, but also costs.