Is her GP unreasonable?

[Spikeyplants]

MIL has had a few bouts of shortness of breath in recent years. Previously, she had blood tests, Xray, cardiac ultrasound and started on a short course of fluid pills. She improves for months, but its back again. This time, GP organised bloods and because they were normal- suggested she goes to A&E for further treatment/advice! She isn't so short of breath she is going blue, but can't walk very far and its affecting her being able to shop, do laundry, clean etc.

Surely the GP should be referring her to a specialist, doing more testing or trying the fluid pills again rather than suggesting A&E. Any advice appreciated.

My dad had similar and they sent him to a and e for checks and he ended up getting taken straight up to the cardio ward and then had ongoing appointments with the cardiologist. All under control now but I think for this area anyway it was a quicker route than a referral that would take months. Fluid in the lungs can be bad news so it's best it's looked at quickly.

They got it under control for my dad and no more pills now. He also found the fluid pills really disrupted his life because he always needed to pee and was self conscious about going anywhere so being under cardiac services actually resolved the issue rather than constantly ending up back on them

Thanks @WarmLilacHiker for posting such a positive and sensible reply.
When I read the post, I thought oh yeah, so many GPS don't prioritise the healthcare of elders, some do of course but I think you're lucky if you find one from my experience with my DPS and other elderly relatives.
I'm glad it worked out so well for your dad, it certainly does sound like a quicker route than waiting for months for referral to a cardiologist. I'd like to think that the GPs know that this is what will happen, and I wish your MIL the best @Spikeyplants .

They can do both. If the issue is such that symptoms are intermittently acute it makes sense to be seen urgently at that point. In the meantime they can refer to the hospital to be reviewed in the relevant specialist clinic.

It makes sense to go to A&E during an acute phase. I wonder if the GP isn’t referring her on as they don’t know if it is her heart or lungs or something else but I would be very unimpressed if my GP did this.

Exactly the same happened for my dad. He’s now under the care of the cardiac failure unit at his local hospital because they are the specialists.

It’s not an accident or emergency?! The GP sounds lazy, they need to do a referral to an appropriate outpatients department -lm assuming cardiology or respiratory. This is partly why A&E is so clogged up

To be fair it took over a year for a cardio appointment to come through for me, I was put on tablets and supposed to be seen again within 3 months, a year later I haven't been seen and just been sent a letter to say they've reviewed me digitally and I'm all good and can carry on taking these tablets (ivabradine, serious stuff).

I'm actually ok, but what I'm saying is...maybe they know the wait list is huge and is only being brought down by what is really a false economy of pushing people off the books without even a telephone call.

When you say x-ray, cardiac and ultrasound was this done in the hospital?

My ex Mil, who I was close to, had cardio vascular difficulties for over a decade and was passed from pillar to post. Unfortunately she died a few days after heart surgery that she should have had at least 5 years earlier.

I suggest that she be accompanied when she next has an appointment with the GP and double book, so 20 minutes. Insist on a referral to a specialist.

There is not enough information here to say whether the GP is unreasonable or not. GP has the full picture, none of us do.

Thanks everyone.
When you say x-ray, cardiac and ultrasound was this done in the hospital?
Yes. It was done within a hospital but I'm unsure if from an exacerbation and she went to A&E back then or referral from the GP. DH and I were working abroad at the time so I don't know all the details.

MIL's GP hasn't been great IMO in many other ways. Due to lack of any help, she saw a private specialist for an unrelated injury to the shortness of breath. It was for her wrist. The specialist recommended XYZ for the GP to do and a referral by GP to a different specialist. Months went on and MIL enquired what was happening with her referral. Her GP said he didn't think she'd want to see a specialist, so didn't forward on the referral!!! She absolutely DID want the referral and insisted on it being made. GP hadn't asked her at all!

MIL now thinks her GP is annoyed she went private for another thing. I too worry about her using A&E when its not an emergency, her sitting in A&E for hours and also her GP being so dismissive and not even doing a cardiac/respiratory referral in the interim- even if she has to wait.

the problem with shortness of breath is that it's a symptom, not a diagnosis and it can be caused by a billion and one things. Without a diagnosis you're rather limited in what you can treat and it sounds like the very sensible initial tests that the GP's done haven't been that revealing. You could keep giving diuretics and that may well help a few causes of the symptoms, but it might not fix the underlying cause (and indeed might make some things worse). The 'traditional' management for SOB in the elderly used to be a touch of 'co-salbut-amoxi-fruse', which would make the patient happy because one of them would probably fix the immediate problem but you probably wouldn't know which it was that did the job, it probably wouldn't fix the underlying cause and it wouldn't stop it coming back so it's pretty poor medicine and it sounds like her GP is trying to avoid that sort of bad practice.

Even if they did pick the right specialty to refer to, the GP will be very acutely aware of the waiting times for a routine appointment and that your MIL could suffer real harm while waiting. A referral to the general medics may be an option to exclude any of the serious nasties, but often for SOB they'll say go to ED and they'll see the patient there (where there are more resources to manage the serious stuff if necessary) and the the wait to see the gen medics might not be any less than just rocking up at ED.

If she's experiencing acute shortness of breath where she is unable to mobilize, then yes, it is an emergency and should be treated as such. And a visit to A&E would be appropriate.

The problem is, there are many things that can cause acute shortness of breath. Some of them won't necessarily have symptoms when they are not active - e.g. allergy, tachycardia or atrial fibrilation. By attending A&E during an acute episode, she can have an ECG, respiratory investigations, etc where the problem is likely to be visible.

You’re annoyed that her GP has taken it seriously enough to advise she’s seen at hospital the same day rather than being added to a really long waiting list? You would also be annoyed if they didn’t escalate soon enough and she deteriorated while waiting for an appointment, and that outcome would be much more serious for her. No wonder GPs are leaving the profession in droves, if they even get complaints for escalating serious symptoms promptly.

Agreed.
She is unwell enough to need hospital.
The GP cannot do and get test results today.
Recent tests have not given a clear diagnosis so treatment is unclear.
Fluid pills can cause acute kidney injury and need monitoring and they didn’t solve the problem.
They don’t think she can wait for a referral.
If you might not need admission you can be sent to ambulatory care in our area but the GP discusses it first with the consultant and for some problems ambulatory care advise send to A+E which in our area is consultant led and has access to scanning etc.
waiting in A+E is not nice but hopefully will give a clearer cause of the problem and a treatment plan. Hope she gets an answer.

Hopefully she will be admitted and they can run some more tests over the next few days and try ti get to the bottom of it. I agree with the gp if he had referred her she could be on a waiting list for months/ years to a consultant who is not even the right speciality

Have they done spirometry?
Has she been a smoker?

I've been having trouble with my heart recently - pain, palpitations, dizziness and an episode of fainting. I went to my GP last Wednesday who sent me up to A&E the same day even though at the time I was okay and to me didn't warrant A&E.

He explained that it's a lot faster than a referral to cardiology, and he was right - in A&E I had scans, xrays, tests and spoke with 3 different consultants. Both follow up appointments (an echocardiogram and a holden monitor) have been booked for this week, so a really quick turnaround.

So whilst I did question at the time why I was being sent to A&E, I can see now how much faster it's been for me to get seen and investigated, whereas I'd probably not even have had a first appointment yet in my area if I'd been referred to cardiology.