Intended for healthcare professionals

Rapid response to:

Views & Reviews If I Ruled the NHS

Don’t mention the P word

BMJ 2015; 350 doi: (Published 06 May 2015) Cite this as: BMJ 2015;350:h2345

Rapid Response:

Communication and Cohesion

I believe that anyone who can write such an emotive article has a duty to institute the improvements they champion, rather than simply publishing their catharsis.

I do agree with some aspects of this article. Fragmentation of services is a pervasive problem and may have in part been due to sub-specialisation. However, this is simply a reaction to the expanding research base and the ideology that management should be standardised and evidence-based.

Therefore, I feel we need to embrace this change and improve the cohesion of and communication between services. Ironically, I feel that this article attacks both recognises the problem and attacks the solution.

The simple fact is the specialist is the authority on how to refer to their specialty. They know what’s relevant and want distilled information to improve the efficiency of triage and the consultation. The 2 week wait pathway is perhaps one of the most well-known and almost exclusively employs referral pro-formas. As a result cancers are being diagnosed quicker and at earlier stages and long-term survival rates have been improved [1][2].

The pro-forma and single narrative letters have been directly compared for years. There are a multitude of studies to testify to the pro-formas superiority in both information quality and ease of use for referrer and specialist. [3][4][5][6].

However, pathways and protocols aren’t always going to be the answer. Those with symptoms that can’t be pigeon holed often bounce between specialties experiencing diagnosis via exclusion. I think we need to resurrect the true general medic to manage patients with diagnostic uncertainty and inter-specialty complexity. This would undoubtedly reduce the patients’ perception of service fragmentation and improve outcomes.

1. Sidu MS, Gulati AG, Hawkins PH, Cooper SC. Improved Lung Cancer Referral Rates And Early Diagnosis In A District General Hospital. Thorax 2014;69:A106 doi:10.1136/thoraxjnl-2014-206260.211
2. Jensen KH, Maina PJ. Cancer pathways are associated with improved long-term survival.
Dan Med J 2015;62(2):A5000
3. Couper ID, Henbest RJ. The quality and relationship of referral and reply letters. The effect of introducing a pro forma letter. S Afr Med J. 1996 Dec;86(12):1540-2.
4. Dupont C. Quality of referral letters. Lancet. 2002;359:1701.
5. Rawal J, Barnett P, Lloyd BW. Use of structured letters to improve communications between hospital doctors and general practitioners. BMJ. 1993;307:1044.
6. Jenkins S, Arroll B, Hawken S, Nicholson R. Referral letters: Are form letters better? Br J Gen Pract. 1997;47:107–8

Competing interests: No competing interests

09 May 2015
Rebecca H Smith
Clinical Fellow
Portsmouth QA Hospital