What works: Mitigating inequalities in patient self-referral to specialist services
Self-referral of patients directly to specialist services may help relieve pressure from GPs; however, concerns have been raised that this may increase inequalities. This brief presents recommendations to mitigate the potential of self-referral to increase inequalities.
What works: Mitigating inequalities in patient self-referral to specialist services[PDF 129kb]
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General practice is currently under considerable pressure because of a mismatch between supply and demand. Self-referral of patients directly to specialist services may help relieve pressure from GPs; however, concerns have been raised that this may increase inequalities.
Based on our review of 19 studies, we found evidence that generally, self-referral services tend to be used more by higher socioeconomic groups, white groups, women, and young populations, although these patterns were not consistent in every context.
We did not find any evidence of interventions to mitigate the potential of self-referral to increase inequalities. In the absence of direct evidence, we developed the following recommendations based on transferable evidence-informed principles to address inequalities: targeting self-referral at those in greatest need, such as rolling out in areas of socioeconomic disadvantage; increasing capacity in those areas; prioritising conditions linked with disadvantage; ensuring the pathways are flexible, culturally competent, and co-designed; and monitoring use and outcomes disaggregated by disadvantaged groups.
Current challenges
General practice is the gatekeeper for most secondary care services. However, it is under considerable strain with a mismatch between demand and capacity. This has led to a drop in overall patient satisfaction in general practice to the lowest recorded. Data from the GP Patient Survey found that overall satisfaction in general practice is down from 83% in 2019 to 71% in 2023 (1). Patient satisfaction with access has also dropped substantially; from 68% in 2019 to 50% in 2023 (1).
One approach to help improve access for patients is self-referral or direct access pathways: routes to accessing specialist care without referral from a GP. As of May 2023, over 30,000 patients self-refer each month in the NHS for sexual health services, antenatal care, optometry, audiology, physiotherapy, alcohol and drug services, smoking cessation, and some psychological therapies.
Those in favour argue that self-referral empowers patients to take control of their own health while reducing the workload for GPs. However, critics raise concerns about inappropriate use of specialist services and an increase in inequalities because those with greater health literacy are more likely to be aware of and navigate self-refer pathways.
Summary of evidence
There was no evidence examining interventions to address inequalities in self-referral. However, we identified 19 articles which examined the relationship between self-referral and health inequalities. Nine studies focused on physiotherapy, six on mental health and psychology services, and one each on cancer specialists, chronic venous insufficiency, health coaching, and hepatitis C support.
Socioeconomic status
Ten studies reported on socioeconomic status. Four studies found that the most affluent patients were most likely to self-refer (2-5). Six studies found that the most educated groups with higher levels of qualification were more likely to self-refer (3, 6-10). Looking at physiotherapy referrals, Leemrijse (2008) found that higher education was the strongest predictor for self-referral, and those with a higher level of education were twice as likely to self-refer in Scheele (2014) and Lankhorst (2020) (7, 8, 10). Bishop (2017) found no difference between self-referral or GP referral rates to physiotherapy amongst those with no qualifications (4). Of the six studies that explored employment status, two found that those who were employed were more likely to self-refer. However, Brown (2014) found unemployed people were more likely to self-refer to psychological services, perhaps because of a higher prevalence of mental illness, while the other studies found no difference between employment groups (11).
Ethnicity
Eight of the studies explored the association between ethnicity and self-referral. Of these, five of the studies found that minority ethnic groups had lower rates of self-referral, suggesting a widening of inequality (2-4, 6, 11). Brown (2014) found no difference by ethnicity; however, the authors did find that ethnic groups were overall under-represented in all referral routes to psychological services (11). By contrast, Clark (2009) found that in the more ethnically diverse site of Newham, individuals from the black community made up a significantly larger proportion of the self-referral group (22.2%) to psychological services compared to the GP referral group (15.9%) (12). However, the authors found no difference in the predominantly white community of Doncaster. Finally, Horrell (2014) found that, compared to the demographics of the local population, the proportion of self-referrals to psychological services was more than 1.5 times likely to be Black and more than twice as likely to be Asian or of mixed ethnicity (13).
Age and gender
Eight studies, of which three explored referrals to psychological services, found no significant difference between the genders in terms of rates of self-referral (2, 3, 8, 9, 11, 14-16). Four studies found that women were more likely to self-refer, accounting for 73.8% of self-referrals in O’Hara (2015) and 80% in Horrell (2014) (4, 6, 13, 17).
Fifteen studies explored the association between patient age and self-referral. Of these, seven studies found no significant difference in self-referral rates by age (3, 4, 6, 13-15, 17). Seven other studies, however, found that self-referral patients were more likely to be younger (7, 8, 10, 11, 16, 18, 19). Hoffmann (2019) was the only study to find that self-referral patients were slightly older (3.4 years) than referrals from GPs to psychological services (9).
What works: key recommendations
We did not find any evidence of models of self-referral which seek to address inequalities. The available evidence highlights the potential for self-referral services to be used more by higher socioeconomic groups, white groups, women, and young populations. In the absence of direct evidence, the following recommendations are given, based on the following evidence-informed principles:
- Addressing geographic inequalities in the distribution of services
- Focusing on conditions which have the strongest association with disadvantage
- Flexible and convenient
- Culturally competent
| Recommendation | Target audience | GRADE certainty |
| Consider implementing self-referral in areas of greatest need first, before rolling out more widely | Practices/PCNs/ ICBs | ⊕
Very low |
| Health planners should ensure that capacity is distributed proportionately to need, such as providing more appointments in socioeconomically disadvantaged areas | ICBs/Nationally | ⊕ ⊕ ⊕
Moderate |
| Consider direct access for conditions that are intrinsically linked with disadvantage, such as smoking, drug and alcohol addiction and obesity. Additionally, consider direct access for specifc patient groups, such as those with severe mental illness, homeless populations or people seeking asylum and refugees | Practices/PCNs/ ICBs | ⊕ ⊕
Low |
| Self-referral pathways should be flexible to allow access for people without digital access, transport or other needs | Practices/PCNs/ ICBs | ⊕ ⊕
Low |
| The process for self-referral should be as easy as possible for patients because activities which require more effort or resources from patients tend to increase inequalities | ICBs/ National | ⊕ ⊕
Low |
| Ensure that pathways are designed in a culturally competent manner, such as ensuring information in different languages and considering patients’ preferences regarding staff gender | Practices/PCNs/ ICBs | ⊕ ⊕
Low |
| Data disaggregated by socioeconomic group and ethnicity is needed to understand and track inequalities in the use of self-referral | Practices/PCNs/ ICBs | ⊕ ⊕
Low |
| Decision makers should include the lived experience of disadvantaged patients in the design and monitoring of services | Practices/PCNs | ⊕ ⊕
Low |
Case study
Insight Healthcare in the East Midlands undertook an initiative to increase access for refugees and people seeking asylum to Improving Access to Psychological Therapies (IAPT). The team identified a substantial shortfall in the number of refugees and people seeking asylum who had been referred to IAPT. Through a multi-agency approach, a new transparent pathway for refugees and people seeking asylum was established. Forging effective relationships with refugee forum staff and clients, as well as training professional interpreters in Cognitive Behavioural Therapy, was key to the increase in self-referrals at the end of the 6-month evaluation.
How this brief was produced
What is the Living Evidence Map on What Works to address health inequalities in primary care?
Using AI-powered software, called EPPI-Reviewer, the Health Equity Evidence Centre has developed a series of Living Evidence Maps presenting evidence of what works to address health inequalities in primary care. The software identifies research articles which examine action-based interventions to address inequalities. More information can be found on the Health Equity Evidence Centre website.
References
1. O’Dowd A. GP patient survey: Getting an appointment is harder but decline in satisfaction slows. bmj. 2023;382.
2. Rocks S, Glogowska M, Stepney M, Tsiachristas A, Fazel M. Introducing a single point of access (SPA) to child and adolescent mental health services in England: a mixed-methods observational study. BMC Health Serv Res. 2020;20:1-11.
3. Pollack CE, Rastegar A, Keating NL, Adams JL, Pisu M, Kahn KL. Is self‐referral associated with higher quality care? Health Serv Res. 2015;50(5):1472-90.
4. Bishop A, Ogollah RO, Jowett S, Kigozi J, Tooth S, Protheroe J, et al. STEMS pilot trial: a pilot cluster randomised controlled trial to investigate the addition of patient direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain. BMJ Open. 2017;7(3):e012987.
5. Holdsworth LK, Webster VS, McFadyen AK, Group SPSRS. Self-referral to physiotherapy: deprivation and geographical setting: is there a relationship? Results of a national trial. Physiotherapy. 2006;92(1):16-25.
6. O’Hara B, Eggins D, Phongsavan P, Milat AJ, Bauman AE, Wiggers J. Piloting proactive marketing to recruit disadvantaged adults to a community-wide obesity prevention program. Public Health Res Pract. 2015;25:e2521521.
7. Scheele J, Vijfvinkel F, Rigter M, Swinkels IC, Bierman-Zeinstra SM, Koes BW, et al. Direct access to physical therapy for patients with low back pain in the Netherlands: prevalence and predictors. Phys Ther. 2014;94(3):363-70.
8. Lankhorst N, Barten J, Meerhof R, Bierma-Zeinstra S, van Middelkoop M. Characteristics of patients with knee and ankle symptoms accessing physiotherapy: self-referral vs general practitioner’s referral. Physiotherapy. 2020;108:112-9.
9. Hoffmann D, Rask CU, Hedman-Lagerlöf E, Eilenberg T, Frostholm L. Accuracy of self-referral in health anxiety: comparison of patients self-referring to internet-delivered treatment versus patients clinician-referred to face-to-face treatment. BJPsych Open. 2019;5(5):e80.
10. Leemrijse CJ, Swinkels IC, Veenhof C. Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy. Phys Ther. 2008;88(8):936-46.
11. Brown J, Ferner H, Wingrove J, Aschan L, Hatch S, Hotopf M. How equitable are psychological therapy services in South East London now? A comparison of referrals to a new psychological therapy service with participants in a psychiatric morbidity survey in the same London borough. Social psychiatry and psychiatric epidemiology. 2014;49:1893-902.
12. Clark DM, Layard R, Smithies R, Richards DA, Suckling R, Wright B. Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour research and therapy. 2009;47(11):910-20.
13. Horrell L, Goldsmith KA, Tylee AT, Schmidt UH, Murphy CL, Bonin E-M, et al. One-day cognitive–behavioural therapy self-confidence workshops for people with depression: randomised controlled trial. The British Journal of Psychiatry. 2014;204(3):222-33.
14. Mutsaers BJ, Janssen FJ, Koes BW, Pool-Goudswaard A, Verhagen AP. Differences in Patient Characteristics, Number of Treatments, and Recovery Rates Between Referred and Self-referred Patients With Nonspecific Neck Pain in Manual Therapy: A Secondary Analysis. Journal of Manipulative and Physiological Therapeutics. 2020;43(6):559-65.
15. Doucette K, Robson V, Shafran S, Kunimoto D. Improving access to care by allowing self-referral to a hepatitis C clinic. Canadian Journal of Gastroenterology and Hepatology. 2009;23:421-4.
16. Fischer T, Hähnel A, Jordan M, Bauer V, Dresler C. Referral by a general practitioner versus self-referral to a specialist practice. A comparison using chronic venous insufficiency as an example. Deutsche Medizinische Wochenschrift (1946). 2003;128(43):2242-7.
17. Mallett R, Bakker E, Burton M. Is physiotherapy self‐referral with telephone triage viable, cost‐effective and beneficial to musculoskeletal outpatients in a primary care setting? Musculoskeletal care. 2014;12(4):251-60.
18. Swinkels IC, Kooijman MK, Spreeuwenberg PM, Bossen D, Leemrijse CJ, van Dijk CE, et al. An overview of 5 years of patient self-referral for physical therapy in the Netherlands. Phys Ther. 2014;94(12):1785-95.
19. Pendergast J, Kliethermes SA, Freburger JK, Duffy PA. A comparison of health care use for physician‐referred and self‐referred episodes of outpatient physical therapy. Health Serv Res. 2012;47(2):633-54.
Suggested citation
Harvey-Sullivan A, Lynch H, Ford J. ‘What works – Mitigating inequalities in patient self-referral to specialist services’, Evidence Brief, Health Equity Evidence Centre, 2024
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