Are written responses to some referrals to a general haematology clinic acceptable?

BMJ 2004; 329 doi: (Published 21 October 2004) Cite this as: BMJ 2004;329:946
  1. Allison Tso, senior house officer in medicine1,
  2. Lucy Harris, medical student1,
  3. Tim Littlewood, consultant haematologist (tim.littlewood{at}
  1. 1 Department of Haematology, John Radcliffe Hospital, Oxford OX3 9DU
  1. Correspondence to: T Littlewood
  • Accepted 11 August 2004


Each year about 1000 patients are referred to the department of haematology in Oxford. Excluded from this number are referrals for problems related to coagulation, which are seen at the Oxford Haemophilia Centre. We wondered whether a written reply to the general practitioner would provide the same quality of healthcare advice more quickly, and with less inconvenience to the patients, than seeing patients in a hospital outpatient clinic.

Methods and results

One consultant (TL) received 274 letters of referral between 1 November 2001 and 1 January 2003 and wrote a response to 121 (table). We subsequently sent each of the general practitioners who had received a written response a questionnaire (box) with a copy of their original referral letter and a copy of the written reply.

Reason for referral of 274 patients to a consultant in a haematological department and whether they were sent a written response or seen in an outpatient clinic

View this table:

TL sent written responses if the patient neither required further investigation (such as a bone marrow biopsy) nor treatment that would better be done in the haematology department and if no evidence indicated a serious underlying illness, such as malignancy. For example, a mild macrocytosis (mean cellular volume less than 105 fl) without accompanying cytopenia was the commonest referral for which TL sent a written response. In all patients, the blood film had been examined (and was normal apart from the mild macrocytosis) and advice was offered about checking for possible causes of macrocytosis (including vitamin B-12 or folate deficiency, liver disease, hypothyroidism, drug related causes, and excess alcohol consumption), if these factors had not already been considered. TL recommended that the full blood count be repeated in three to six months and that the patient be re-referred if either the macrocytosis had worsened or a cytopenia had developed.


Was a written reply offering advice rather than an outpatient appointment acceptable to you? Yes/No

Was the advice given helpful to you? Yes/No

Would you be satisfied with a written response in the future if thought appropriate? Yes/No

Do you know if the patient was satisfied with a written response? Yes/No

Invited other comments

We received anonymous replies from 104/121 questionnaires. Of the 104 responses, 101 said that a written response was acceptable and 103 said that the information given was helpful. All the respondents said that they would be satisfied with a written response in the future when deemed appropriate. Seventy two patients were thought to be happy with a written response. The remainder had not been asked for their opinion.

We also received 39 favourable comments, but one general practitioner felt that patients expect to see a consultant after a referral and another felt that anyone needing an explanation of any sort of haematological problem should see a specialist rather than having it explained in writing.


Selected referrals to a general haematology clinic can be managed by written responses rather than patients being seen in a hospital clinic. The pattern of referrals to the clinic was similar to those referred to Leeds General Infirmary in 1989.1

What is already known on this topic

No published studies of a similar nature could be found

What the study adds

Some patients with abnormalities suggestive of a haematological disorder do not need to be seen in outpatient clinics but can be well managed by a written response to the referring doctor

A weakness of this study is the lack of analysis of the patients' opinions about a written response. Most general practitioners felt that the patient was happy with the strategy, but any follow up study should ascertain this more formally.

We learnt from the small number of unfavourable comments to include a final sentence in all letters stating that if the referring doctor or the patient was not happy with the written response that they would be seen in the clinic. Since completing this study, five of the patients have been re-referred, of whom three were then reviewed in the outpatients clinic.

We are conscious that this system worked well in one discipline, in one hospital in the United Kingdom. Although it may not be applicable in other settings, this system should at least be applicable to some other haematology departments.


This article was posted on on 1 October 2004:

We thank all the general practitioners who completed and returned questionnaires.


  • Contributors TL wrote the written responses and was primarily responsible for writing the paper. AT and LH did the audit. TL is guarantor.

  • Funding No additional funding.

  • Competing interests None declared.

  • Ethical approval Not needed.


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