064 Referral guidelines or tramlines: exploring when not to refer

<h3></h3> Guidelines have become a dominant force in many modern healthcare services, where they are often interpreted as rules that cannot be broken. In the UK’s National Health Service (NHS), a body called NICE produces evidence-based recommendations for health and care in England and Wales. NICE guidelines aim to improve the consistency and quality of NHS care by offering advice on best practice on how to diagnose and treat medical conditions. They also offer recommendations to general practitioners (GPs) on who should be referred to see secondary care specialists, and when and how this happens. Despite their emphasis on uniformity and standardization, referral guidelines do generally enable GPs to make exceptions. This can include referring patients who do not technically meet referral criteria but who the GP strongly suspects has a serious disease, such as a malignancy. This space for making exceptions allows GPs to make use of their professional intuition and their relational knowledge of the patient in their referral decisions. However, NICE guidelines do not offer guidance on what to do when a patient <i>does</i> technically meet referral criteria, but the GP suspects they <i>do not</i> have a serious disease or that sending them for investigations and treatment would cause more harm than good. Should the patient be referred in any case, to be compliant with guidelines, even if the GP fears that doing so would lead to unnecessary medical interventions? It is likely that as things stand, not referring leaves GPs vulnerable to blame, or even medico-legal consequences. This lack of guidance on <i>not referring</i> can put GPs in a difficult position, unsure of how to provide the best care for their patients while also protecting themselves. The dominant discourse of patient ‘safety’ trumping all other considerations (and how this so-called safety is conceptualized) contributes to this. Over-investigation has become ethically justifiable, making under-investigation ethically dubious. This seminar explores a series of case studies drawn from clinical experience of instances in which healthcare professionals may be justified in declining further investigations, even when doing so is contrary to the guidelines. Through guided discussion, we will explore the following questions. When might it be appropriate to not refer patients, even when doing so is contrary to guidelines? What might be the consequences of making more conservative referrals? How can we better support GPs and consultants to make these decisions according to their professional judgement and relational knowledge? What might alternative pathways look like? How can the complexity of referral decisions be communicated to patients and other healthcare professionals? Facilitated by a GP and researcher/patient representative, the seminar will offer a unique opportunity to explore the messiness surrounding these issues.