Could non-doctor referrals cause waitlists to blow out?

The RACGP and the AMA have both raised concerns, but a PHN board chair and health economist argues the main concern is digital connectivity, which may be on the up.

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The number of unnecessary referrals to non-GP specialists from “direct referral pathways” is unlikely to be significant, but digital connectivity will need to improve, says a PHN board chair and health economist. 

Last week, Professor Mark Cormack and his team released the final report of the long-awaited Scope of Practice review, including a recommendation to expand non-doctor referral power. 

The “direct referral pathways” would allow patients to access non-GP specialist rebates when referred by a non-doctor working “within their scope of practice”. 

Both the RACGP and the AMA expressed concerns, including blown out wait times and patients unnecessarily sitting on said wait lists for needs “squarely within [a GP’s] scope”. 

Speaking to The Medical Republic, chair of the board of Eastern Melbourne Primary Health Network and health economist Professor Stephen Duckett said that for specialist wait lists to expand in any substantial way, there would have be a significant number of people who either needed to be referred to a specialist and were currently missing out – presumably due to access constraints – or those who may be unnecessarily referred. 

Professor Duckett said there was no evidence of how large the latter group would be, but it was “probably quite small”. 

He said it was important to note that the recommendation remained “very tight”, in that a limited number of professions would be able to refer to “cognate specialists”. 

In the first instance, the Scope of Practice report recommended limiting the expanded referral power to specific non-doctor professions.  

This would include allied health – such as physiotherapists, speech pathologists, psychologists, dietitians and diabetes educators – midwives, nurse practitioners and remote area nurses. 

It would also limit which specialists each profession could refer to for the rebates to be accessible. 

Professor Duckett said this group of professionals “ought to know their business” and understand the need for a specialist referral and what was beyond the remit of a GP. 

Using the example of a physio referring to an orthopaedic surgeon, Professor Duckett said that in some cases, within the public system, this dynamic was already part of the triaging process. 

“What’s been happening over the last 5-10 years is that increasingly, if you’re referred to an orthopedic clinic at a public hospital, you are triaged at the public hospital into whether you see a physio or an orthopaedic surgeon,” he said. 

“So … a whole lot of people who are referred to an orthopaedic clinic by GPs, incidentally actually would benefit from seeing a physio first or instead of [an orthopaedic surgeon].  

“It just seems to me that we’re creating a potential problem that I think is highly unlikely to exist.” 

Professor Duckett said concerns over becoming a “US-style system” were a common occurrence. 

“It’s a criticism that’s been leveled at almost every change in the last 40 years,” he said. 

Professor Duckett said that wasn’t to say there weren’t any risks with the proposal, namely GPs getting cut out of the loop. 

“It’s really important that everything we do is about trying to ensure integrated care, rather than disintegrated care,” he said. 

Under the report’s recommendation, the professional writing the referral would be required to notify the patient’s GP and practice “via digital mechanisms as available” for the non-GP specialist rebates to be accessible. 

However, it is unclear how this would be enforced. 

While the digital connectivity of the health system might not be up to par yet, that’s not to say it wouldn’t be in future, said Professor Duckett. 

“If you want me to stand up and say that My Health Record is working perfectly at the minute, or that electronic interchange between all the parts of the health system is working perfectly, I could also sell you a Harbour Bridge,” he said. 

“It is just not where we want it to be.  

“But that’s not to say it won’t be where we want it to be in five years’ time, there are … changes that are taking place, which this [reform] is going to sit within.” 

Should this reform go ahead, it would be pertinent to work out how to ensure it works effectively – i.e. by building up the digital infrastructure – and how GPs can be kept in the loop, said Professor Duckett. 

“If this is going to happen, let’s make sure it happens in a good way, rather than a silly way.”