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Referral forms - barrier to timely patient care

Coalface tales

James Booth

Thursday, 22 August 2019

AdobeStock_231029480_referral.jpgA rather sobering article in Pulse this week highlighted an issue that has gone from being a nuisance when I started in practice, through to a daily headache for me and countless others, to now being attributed by a coroner as being a contributory factor in the tragic death of a patient. As can be seen from her writing after her hearing, the coroner felt that the rejection of an incomplete form led to a delay in providing care with deeply sad consequences. As she wrote:

“Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided.”

There is a terrible irony that a system that is clearly intended to gather information has here been seen to limit the provision of that information. However, this does reinforce my long-held belief that referral forms exist for the convenience of administrators, not clinicians, and the massive increase in their use represents an under-reported barrier to patient care. 

As I write this, I am sitting with our clinical system open, and I have counted the referral forms that we have currently active on it. I made a small bet with myself before starting that the number would probably just about exceed hundred. I was wrong; we have, at my best count, 188 separate referral forms on our system. If you then include forms that we are sent non-electronically, the forms that can only be done via a website, and those that we have probably left off somewhere, then I think we’re looking at over 200 of the wretched things. I’m lucky, at least, that the vast majority of my referrals go to one hospital trust, one community provider, or one mental health trust. I envisage that those of us working in big cities or midway between two large DGHs have a much bigger problem here.

They vary enormously, from the incredibly simple cardiology one (two tick boxes under “Test Requested,” and that’s it) to the helpful ones that tell you what to put and where, all the way up to the ones that come complete with warnings about them returning any incomplete ones, and some that seem to represent the most ridiculous inefficiency of effort. Our podiatry service has three separate forms, one of which is just for ingrown toenails. One unit has two separate forms for two different types of endoscopy. Radiology forms vary markedly depending on the provider, despite them all being NHS scans. We have one for wheelchair referrals, and a different one for wheelchair cushion risk assessments. There are those that come with a checklist of different things to include (funding approval! Clinical photos! A recent ECG! A separate letter!) and those that seem to delight in making demographic information take up more space than clinical. So many of them carry warnings that, in the light of the story above, now seem to be creating clinical risk by advising any incomplete form will be returned “which may create delay for your patient.”

Of course, I can see why they appeal to a busy office. All of the details in the same place for each patient, and an easy system to reject those that need more information. It’s doubtless more straightforward to rattle through a few dozen identical forms, it’s easier to audit them, it’s probably easier to train people to process them. All good, efficient things, but patient care never fits into easy boxes, and the problems are created upstream of that, at the point of the referral, and isn’t that what the whole process really should serve? I can imagine a team spending some time working out how their form will fit into their administrative set-up, without ever asking the person who’ll be filling it in for input, nor consider quite how many other offices are doing exactly the same across several trusts.

It’s a rather one-sided practice, this. My surgery has not a single form for the use of another clinician to communicate with us. We’ll take a phone call, an email, a letter, a task on SystemOne. We might ask for clarity if there’s confusion, but we won’t just reject the message outright. I can see how standardising the information flow might help my administrative team, but I don’t think it’ll speed anything up really, and it won’t change how I act on anything. I imagine that’s true of all of us in primary care, and yet we’ve ended up in a situation in which we have to keep track of dozens upon dozens of different bits of paper to access the care our patients need. I have no idea how our locum colleagues manage. 

I think the case written about this week, in retrospect, seems to have been inevitable. The timely flow of good clinical information is vital in the NHS, and it seems very sad that at a time in which communication between people is easier than it has ever been, red-taped barriers to this are proliferating about the system. I’ve got a proposal: I’m going to call it the Universal Referral Form. It’s a piece of A4, or an email, with my name and details at the top, then those of the patient, then a bit of writing as to what I’m asking for. We used to call them “letters.” I’m not convinced they have yet been surpassed.

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James Booth

James qualified from UCL in 2002 and has been a GP partner in Chelmsford since 2006. He is also the named GP for Safeguarding Children locally. All views expressed are his own.
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