Do you need a referral to see us?
February 1, 2023
December 7, 2021
By Dr. Andrew Campbell-Lloyd

Do you need a referral to see us?

** EDITED 12/04/2023**

Well, somewhat unexpectedly, there have been some announcements from AHPRA (the health regulator) recently which have upended some of the issues I have referred to in this article. I guess, in retrospect, it has been timely for us to discuss this topic. Having said that, there are a few changes that will be introduced in July this year regarding referrals, and their requirement for cosmetic patients.

The short version is this:

From 1 July 2023, all cosmetic patients will require a referral from a GP for their consultation. That GP cannot be a GP who has a "cosmetic" practice of any sort (that is, it cannot be a GP who performs things like botox or fillers).

The regulator has claimed that their aim in forcing this change is to ensure that patients can "discuss with their GP their motivations for surgery" whilst also acknowledging that the GP providing the referral is unlikely to know anything about the surgery the patient is considering, and nor does the regulator think that lack of such knowledge is relevant in forcing this change regardless. Not sure about the logic there, but so be it.

The interesting part however, for my patients, is this:

Where an item number may apply to a procedure (and I am really talking to my patients considering explant procedures here), then the procedure is deemed reconstructive, and this rule does not apply. So ladies considering explant will not be compelled to obtain a referral, although we will continue to recommend that you have a referral.

So, this will be an important consideration for some patients, and the regulator is also introducing a raft of other changes as part of their so-called "Cosmetic Surgery Review", which was triggered by a number of significant media stories last year.

Oh, one other really (really) important point: When a lady asks her GP for a referral to a private specialist of her choosing, it is not the GP's right, nor their role to then try to refer that lady to a different surgeon. So, if you request an appointment with us, and you then see your GP for a referral, remember it is your right to choose and your GP must respect that.


Plenty in the news lately about the Australian health care system. Is it working? Is it failing? How much can we afford? How do we improve it? What to do about the decline of bulk billing? And the big question (somewhat controversially), what is the role of general practitioners in our current medical system?

It sounds like we are about to see yet another round of “modernisation” of a system that was designed more than 50 years ago and which has not kept pace in any way with the progression of health care delivery and technology.

It seems pretty clear that despite some of the concerns we have in Australia about the “fitness for purpose” that Medicare demonstrates, and the mixture of our health care delivery across public and private systems, there is still a strong consensus that our health system is one of the better models (or perhaps just the least bad model) when compared to other countries.

The latest salvos coming out of Canberra in the never ending politicisation of health care though are not really any more likely to streamline the bloated bureaucracy of Medicare, and nor are they likely to actually change what is happening in terms of health care utilisation or delivery.

We’re (like most western nations) a country that is getting older, fatter, sicker, more medicated, less resilient and generally more inclined to expect the government to do for us what we did for ourselves for many generations – that is, look after our own health.

Anyway, the thing that I guess I wanted to talk about is the specific ways in which our health care systems seem to be failing the patients I see, and I guess that they are a rather different group to the patients that most GPs and their lobby groups speak about in the media - my patients are typically fit, young(er) and considering elective or aesthetic surgery. The focus in the news is almost always on bulk billing in general practice (and why that is no longer feasible for the chronically ill, heavily medicated and generally unfit patients that occupy so much of a GP's time), the role of general practice as a “gatekeeper” to the health system (ie. GPs direct the flows of referrals to specialists, whether public or private) and the over-burdening of public hospital emergency departments due to the issues in general practice. And whilst that is all very relevant, it completely ignores the fact that there are a range of concerns for specialists like me, and patients who need to see specialists like me, that rarely get touched on in these discussions.

The entrenched model of care (and the one that GPs would like to see perpetuated – this is not necessarily a negative judgement of that model I should add, just a commentary on why it isn’t working) is that of a patient with a concern, who sees their GP on the assumption that should they require a referral to a specialist, the GP is the best person to direct that referral to a suitably qualified specialist with expertise in the required field (or more frequently these days, the required subspecialty field).

This model of care is predicated on a number of assumptions,and I would contend that those assumptions no longer hold true.

The first assumption is that for a patient with a given concern (let’s use breast reconstruction after mastectomy as an example), the GP knows something about the topic, and also has some awareness of the specialists who may be experts in that field, what certain forms of care may entail, what they cost, and how they might work. That assumption would be logical, and perhaps 30 years ago it was also true. But with the ever-expanding, progressively sub-specialising nature of health care, it is now abundantly clear that it is in fact a totally false assumption. If my discussions with GPs about a topic like breast reconstruction are anything to go by, many GPs: a)  know little about the options, b) are not sure which specialist(s) to refer to, c) are oblivious the implications of poor outcomes (arising from misdirected referrals), and d) are unlikely to have the time or incentive to educate themselves on such a topic.

The second assumption is that patients seeking a particular service have a regular GP who knows them or has been involved in the continuation of any previous specialist care. Certainly, the nature of oncology services are now such that patients are managed by their surgeon, their oncologist and their allied health teams and very often not in conjunction with their GP. There may or may not be correspondence from those specialists updating the GP on whatever has taken place.

The role of the GP as gatekeeper is already undermined in many respects when it comes to continuing the care of patients who have been managed in acute settings and in hospitals.

The third assumption (and perhaps the one which has been most disrupted in the last 15 years) is that patients look to their GP for information and recommendations. Google, social media and  forums have completely undermined that assumption and particularly when we consider younger patients, many people now have (or think they have) greater knowledge about their own condition than their GPs do (for better or for worse).

The final assumption worth thinking about is the question of private insurance, how it works, and whether GPs understand it. This assumption has to be questioned quite severely based on what I hear and what I see. Perhaps the fact that private insurance is legally not permitted to play a role in general practice has something to do with it, but it seems rather uncommon that a GP is able to have a conversation with a patient about how their insurance might work should they need to see a specialist. As I’ve indicated before, private insurance is actually a little tricky to understand with “no gap”, “known gap” and various out-of-pocket concepts that need to be understood. Perhaps if that antiquated law which prohibits private insurance from covering things like GP and specialist outpatient consultations were repealed, and if patients could use their insurance when seeing their GP, it would force GPs to get their heads around something that many patients would expect them to understand. Such a move could also save patients from that so-called “bill shock” which arrives after seeing a specialist and they are presented with an invoice. There are plenty of cases where GPs (mis)inform patients that when they are referred for surgery and they have insurance, that the surgery will be completely covered by insurance. Which isn’t particularly helpful.

So, it seems to me that the role of GP as the referrer has been subsumed into a role as a mere “facilitator” of a referral to a specialist of a patient’s choosing in many cases.

I accept that this may not hold true in all areas of medicine, but as I said above, this is certainly true for the patients I see and treat.

Many of my patients find me first, and then simply ask their GP to write the referral to allow them to claim a Medicare rebate on their consultation. Beyond that, when I ask people if they wish for me to correspond with their GP, they often say “no”, or they simply tell me that they don’t actually have a regular GP and they only got the referral for the above reason.

Does this matter? I'm not sure. I have spent years providing detailed letters to GPs after consultations, updating them on treatment progress and in doing so, I try to offer information that will allow those GPs to increase their knowledge in the event that they see another patient with a similar concern. Has that actually worked? Who knows.

This is a part of the discussion around the modernisation of health care that needs to take place, but doesn’t. It is a part of the discussion that could have enormous impact on the way sub-specialist care is delivered, but all we hear about is Medicare and GPs’ bulk-billing rates. More importantly it also ties back into the bigger discussion that needs to happen about making our health system more efficient, more patient-centred, and more outcome-driven.

So, to answer the question of whether you need a referral to see us: well, we do recommend it because it still helps, at least a little bit. As I mentioned above, a referral is useful because it may allow you to claim a Medicare rebate on your initial consultation and we can then bulk-bill follow up appointments so that you have no out-of-pocket costs for things like additional consultations or post-op visits (please note that the applicability of rebates depends on whether the purpose of the consultation is purely cosmetic or not). Beyond that though...a referral doesn't mean what it once did. And just as importantly, the process of getting that referral no longer requires that your GP even understands why you want it, nor does it imply that they will have any involvement in your ongoing healthcare after surgery. But I wonder just how much of that we (as specialists) are responsible for? Should specialists shoulder some of the blame due to poor communication (probably), and a failure to engage with primary health care providers (maybe)? Well, I'm not a politician so I can't fix the system. But I do try to help my patients navigate through it.

As always, I am writing generally (out of necessity) and without doubt there will be exceptions to what I have described.