What works: Mitigating inequalities in patient self-referral to specialist services

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.

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.

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).

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

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.

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.

Harvey-Sullivan A, Lynch H, Ford J. Evidence brief: What works – Mitigating inequalities in patient self-referral to specialist services. Health Equity Evidence Centre; 2024.