Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Potential for error
- Peter Gooderham (10 February 2006)
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Consultant to consultant referrals are funded
- Tim E P Davies (14 February 2006)
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Rising to the defence
- David M Lewis (15 February 2006)
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Consultant to consultant referral
- Lesley J Kay (16 February 2006)
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Support with reservations
- Bernard Boyd (21 February 2006)
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Tertiary referrals in theNational Health Service (NHS)
- Peter E D Coates (1 March 2006)
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Peter Gooderham, Tutor Cardiff Law School
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Dr Goodman is to be congratulated on this article, which draws attention to a problem which frustrates GPs and Hospital Doctors alike. It is ludicrous that one professional cannot readily refer to another within the hospital system. Much anecdotal evidence exists to suggest that this is a major problem. Deliberately introducing delay into such a referral system increases the risk of problems arising in the interim. Perhaps the time has come for a formal study of the effects of obstructing efficient clinical referral? If hospital risk managers are not considering this, then why not? The rising practice of asking GPs to make a referral to a second consultant at the request of a first consultant introduces an extra step into the referral process which increases the potential for error and also delay. Many GPs are extremely efficient - they have to be - but is it fair to the GP, or the patient, to erect an unnecessary hurdle to referral which a Consultant considers necessary? I believe not. It should be noted by politicians responsible for the NHS as a whole that giving GPs unnecessary tasks diverts their clinical time from appropriate clinical activity. A Prime Minister who was embarrassed during the 2005 General Election Campaign about access to GPs might usefully consider a serious attempt to remove unwarranted demands on their clinical time and administrative resources. Dr Goodman mentions exercise electrocardiography. In the 1990s - when fundholding existed and there was certainly importance attached to GP referrals - I had control over my exercise electrocardiography lists as a lowly SHO, in two teaching hospitals. It was no problem to accept a referral from a hospital colleague, and providing a prompt service, with immediate reporting, was a source of professional satisfaction. Certainly Hospital Doctors should assert their professional status; it is, after all, in the best interests of patients. Competing interests: 1)Academic interest in preventing medical error 2)Retired Medical Practitioner |
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Tim E P Davies, Director of Public Health South Worcestershire PCT B50 4NT
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Sir Dr Goodman correctly states that consultant to consultant referrals are not part of the monitoring of waiting time standards for trusts and therefore may be given less priority by trust managers. However, he is mistaken in his assertion that consultant to consultant referrals are not funded and that this may also influence how managers behave. Under payment by results all out-patient attendances are charged at tariff. First out- patient appointments have a higher tariff than follow-up attendances but the source of the referral is not relevant. Primary care trusts (PCTs) therefore fund trusts for consultant to consultant referrals in exactly the same way as they do for GP referrals. It is this issue that is driving some PCTs to try to get a better grip on referrals between consultants. There will always be perverse incentives in a bureaucracy as complex as the NHS, but it is important to understand the rules of the system before ascribing possible motives to others. Competing interests: None declared |
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David M Lewis, General Practitioner The Tudor Surgery, Watford WD24 7PH, UK
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Dear Sir Dr Goodman's article is timely. Just today a consultant at my local hospital insisted on speaking with me about a case which was felt needed urgent attention by another department in the same hospital. [Patient and doctor confidentiality preclude me from being too specific]. My PCT (Watford & Three Rivers PCT) has apparently recently decreed that there should be no consultant to consultant referrals forthwith, except in the case of suspected cancer. This is NOT anecdotal - it is happening on my doorstep, and probably yours too (If you work in the UK). In my opinion this is inefficient and does not seem ethical. Certainly, my patient needs an outpatient appointment this week and not wait until April 2006 which is the earliest 'urgent' appointment that I was able to manage even with telephoning the secretary and faxing my referral. Thankfully, the first consultant has managed to get the needed urgent appointment, but only after speaking with me and haggling with the second team. There has been no forewarning of this new state of affairs; the PCT did not see fit to write to local GPs about this issue at all. We have not had a chance to discuss it or lobby for something different, if not preserve the status quo. If ever there was an example of how managers with no clinical knowledge can wield so much power over the fate and wellbeing of the population this is it. The Public should know and demand that this silliness stops. Competing interests: I am a GP who is directly affected by this issue |
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Lesley J Kay, Consultant Rheumatologist Freeman Hospital, Newcastle upon Tyne, NE7 7DN
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Dr Goodman is brave in pointing out the problem of inter-consultant referrals being delayed at the expense of referrals from primary care (which includes nurse practitioners as well as GPs). Targets are an extreme priority for many managers, and whilst I as a clinician do understand this, and find working with shorter waiting lists less stressful than having to prioritise patients who might wait up to a year under the old system, nothing should over-ride the duty of care we have to our patients. It should be remembered that hospital managers also owe such a duty of care to patients, and that prejudicing their care by delaying referrals on anything other than clinical grounds runs against their own code of conduct and the instructions from the Department of Health. Consultant to consultant referrals are a bone of contention, and have been criticised for consultant lack of understanding of current referral guidelines, but there are situations where consultants have a particular knowledge of the condition in question and are in the best position to make further referral. For example, as a rheumatologist working in a Musculoskeletal Unit with orthopaedic surgeons, I'm in a better position to make a referral for foot surgery when I can discuss the patient directly with the surgeon, than the GP or nurse practitioner is. If I suspect a patient has a peptic ulcer, then who takes responsibility if I don't make a referral for endoscopy directly, and the letter to the GP suggesting such a referral goes astray or is not acted on? In my own experience, such delaying of inter-consultant referrals has happened, and has only come to light by audit of waiting times by myself and clinical colleagues. Response to this being pointed out has been unsatisfactory but we are assured it won't happen again. "Payment by Results" may remove one driver to this practice, when there is specific payment for secondary referrals, but waiting time targets do not include these patients, and will probably carry more important consequences. "Choose and Book" will alter the problem. In the preparation I have had for this, such as it is, it was only the consultants that realised we had to keep appointment slots back for inter-consultant referrals; it seemed to come as a new idea to the staff who had come to tell us about the system (at our request). How many teams are going to find that they have nowhere to put these patients when their appointments are given over to external booking? If I were a GP I'd be intensely irritated to be sent a letter and asked to forward it as a referral to some other service, creating unnecessary work and using the GP as a relay. I'd have no problem with my referrals being scrutinised by other clinicians for clinical appropriateness, providing it didn't delay the appointment for the patient. In the change of systems around us we must keep sight of clinical priorities: if a patient needs to be seen then whatever the system they need to be seen as quickly as possible. If referrals from consultants are to take lower priority then this needs to be explicit and a system agreed whereby referrals from consultants are considered and forwarded by primary care, to ensure that referral and treatment is based on clinical need. Competing interests: None declared |
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Bernard Boyd, Family Physician Private Practice
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Our local GP Association has generally not been in favour of direct consultation between specialists. My own feeling is that, in a hospital setting, such a practice is the most efficient and hardly one to be debated. In the out-patient clinic, however, unless the situation demands very urgent referral, the family doctor ought to be involved. The position here may be somewhat different. Perhaps the ethics of the profession in the UK differ from those here, but it is not uncommon for the patient's GP to be completely unaware of the investigations, management or outcome of the patient's illness. It then becomes somewhat embarassing to have the patient appear months later (in the midst of this cross referral, or worse, long after)with no information from either consultant. There would be little or no problem if information was fed from time to time from one or other consultant. B C Boyd Competing interests: None declared |
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Peter E D Coates, Retired Independent School Bursar I no longer work
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Dear BMJ Editor The article by Michael Goodman in your issue of 11th February, and the correspondence to which it has subsequently given rise, have recently been brought to my attention. As a layman patient, I had cause last year to feel aggrieved after I was referred at the end of 2004 by my renal consultant to an orthopaedic consultant colleague at another local hospital. I received a letter dated 27th January offering me an appointment on 25th July, which enabled me to avoid this date when booking my summer holiday. A second letter dated 16th June changed the date to 28th July, which did not clash with my holiday, the booking of which by this time had been confirmed, and a deposit paid. Yet another letter dated 23rd June changed the date again to 14th July, which fell in the middle of my planned holiday. I immediately rang the appointments office, explained the problem, but the best they could do was to offer me an alternative appointment on 29th September! My irritation became unbearable when on the very morning I expected at last to see the orthopaedic consultant, I received yet another letter deferring the appointment until 16th March 2006 as the consultant’s clinic on 29th September had had to be cancelled at the last minute. In the circumstances, I felt constrained to write at once to my Member of Parliament (MP)to vent my profound disappointment at this intolerable series of deferments. I copied my letter to the consultant with whom I was expecting an appointment, and he replied saying that his clinic on 29th September had had to be cancelled in order that he might complete an NHS target by performing non-urgent operations. I sent a copy of his letter to my MP, who had referred the matter to the Chief Executive Officer (CEO) of the NHS Trust concerned. His reply, which suggested that my last appointment had been cancelled because the consultant was required to carry out “urgent surgery”, also intimated that whilst GP to consultants referrals were subject to NHS target dates, in cases of “a consultant to consultant referral the (NHS) Trust is not obliged to ensure that the appointment is within Government targets”. As a result of these exchanges, it was possible to bring forward my appointment from 16th March 2006 to 12th December 2005. The most interesting point was that the reason given by the consultant for the 29th September cancellation at that of the NHS Trust CEO did not correspond. My MP, I am pleased to say, picked up on the difference in treatment between a General Practitioner (GP) to consultant referral and a so-called tertiary referral from one consultant to another, and promptly, on 24th November, wrote to Patricia Hewitt, the Secretary of State for Health, saying: “I strongly feel that this method of (tertiary) referral should fall within Government Targets and would appreciate it if you would inform me of your views on this matter.” I received a copy of this letter, as I did of the reply, towards the end of January, after parliament had resumed after the Christmas recess. It came from the Minister of State, Lord Warner. He waffled on unconvincingly about what had been achieved in the NHS under the present administration, intimating that by 2008 the promised improvements in patients’ waiting times would be reduced to forecast levels. He failed to address specifically my assertion that unacceptable discrimination exists when referral by consultants to consultants are not subject to the waiting time targets which apply to referrals by GPs. I said as much to my MP, and I have heard nothing since. I remain concerned, I am sure like many patients in a similar position, that the Department of Health is not responding properly to the needs of patients who need specialist advice or treatment and whose cases are referred from one consultant to another. I apologise for the length of this letter, but I felt it important to tell the full story. Yours truly Peter Coates Competing interests: None declared |
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