The European study of referrals from primary to secondary care

Abstract

This model i s concerned almost exclusively with demand and need in relation to individuals.Need is not necessarily defined in terms of the individual.Some of the most important needs of healthcare are related to communities.As an example, the concept of universal immunisation/vaccination in order to eradicate a disease involves an entire community and not just individuals concerned with t h e i r own welfare.Preventive medicine is concerned more with the needs of individuals and of communities but not with their demands.Medical care has changed direction during the l a s t twenty y e a r s .Hitherto, patients consulted doctors of their own i n i t i a t i v e whereas now it is incumbent upon doctors to seek opportunities for delivering healthcare.This attitude has received support by the British Department of Health in the provision of financial inducements for general practitioners to achieve certain standards of preventive care.While on occasions, need for care may be evident, patients may not make any demand.Particular symptoms may indicate the need for prompt medical care but their importance may go unrecognised and demand not made.Some patients consult other perhaps non medical persons; some deny need out of religious conviction; others deny need out of ignorance.The availability of a l t e r n a t i v e s e r v i c e s of healthcare and the direct costs associated with obtaining these influences the extent to which p a t i e n t s consult (and need referral).The availability of osteopaths for example, w i l l influence the extent to which persons consult general practitioners for back problems.Particular symptoms may indicate the need for prompt medical care but their Importance may go unrecognised and demand is not made.The relationship between demand and need, as well as having individual and community components, has a national norm which is a product of national c u l t u r e , attitudes to healthcare and a v a i l a b i l i t y of s e r v i c e s provided.The differing national relationships limit direct comparison of national statistics for referral.Functional Divisions By d e f i n i t i o n , the term general practitioner implies a capacity t o do everything.Loudon and Stevens (1980) model the evolution of h e a l t h c a r e p r o f e s s i o n a l s over the last century from the mixture of educated gentlemen (the physicians of the 18th century) and the tradesmen (chemists and druggists) to the highly trained professionals of today (Fig.1.4).F i g . 1 .4 THE EVOLTUION OF THE GENERAL PRACTITIONER AND CONSULTANT 1 9 t h C e n t u r y a n d b e f o r e Present day Physicians -* ^ ^ » Consultants General Practitioners Pharmacists .Chemists & Druggistsr e g i s t r a t i o n e x i s t s for primary care but some specialists (e.g.dermatologists >, operate in primary care with open access to p a t i e n t s with skin problems.Where s p e c i a l i s t s are available as primary care physicians with open access t o p a t i e n t s , there will be a consequent impact on the d i s t r i b u t i o n of h e a l t h problems brought to the general p r a c t i t i o n e r s and a knock-on effect on his referral pattern.By t h e same t o k e n , t h e s e s p e c i a l i s t s are likely to be less s p e c i a l i s t i n function consulted by a comparatively unsorted group of s i c k p a t i e n t s .At the minimum, the filtering effect of r e f e r r a l e n s u r e s t h a t patients arrive at an appropriate s p e c i a l i s t department and patients with less severe illness are excluded.The Alma Ata Declaration (WHO, 1978), emphasise the fundamental role of primary healthcare in moving towards the goal of equality of h e a l t h (or at l e a s t of healthcare).Today's national d i f f e r e n c e s are not compatible with that goal, though it would be f o o l i s h t o c o n s i d e r movement towards this objective without c o n s i d e r i n g a l l the o t h e r related facts, especially those concerned with differences i n medical manpower.Competence • • • • .( : • • "Competence d e f i n e s what a doctor is capable of, whereas performance i s concerned simply with what he does", (Senior, 1976) .The competence of the doctor consulted is of course highly relevant t o the r e f e r r a l process.It is necessary not only to c o n s i d e r h i s a c t u a l competence, but also his perceived competence.At the extreme, a patient may not consult if he b e l i e v e s the doctor i s not competent to deal with his problem or, i f he c o n s u l t s , may demand referral believing his problem calls f o r more s p e c i a l i s t a t t e n t i o n .Attitudes change with time (Cartwright and Anderson, 1981) and so does competence.Competence i s the product of training and experience.Modern t r a i n i n g for g e n e r a l p r a c t i c e in countries such as the Netherlands and the United Kingdom, includes the conventional academic t r a i n i n g , e x p e r i e n c e in a range of junior hospital s p e c i a l t y p o s t s , an apprenticeship in general practice and a continuing programme of educational activities, some of which p r o v i d e a d d i t i o n a l s p e c i f i c qualifications.Since training opportunities in some countries are much more limited, so also is the competence of the general practitioner.t .10 TABLE 1.2-POPULATION AND MEDICAL MANPOWER(per 100,000)BY COUNTRY G e n e r a l A c t i v e practitioners Population general All aa % (m) practitioners doctors a l l doctors Belgium

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