Intended for healthcare professionals


Defending referrals between consultants

BMJ 2006; 332 doi: (Published 09 February 2006) Cite this as: BMJ 2006;332:371

Consultant to consultant referral

Dr Goodman is brave in pointing out the problem of inter-consultant
being delayed at the expense of referrals from primary care (which
nurse practitioners as well as GPs). Targets are an extreme priority for
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
managers also owe such a duty of care to patients, and that prejudicing
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
but there are situations where consultants have a particular knowledge of
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
or nurse practitioner is. If I suspect a patient has a peptic ulcer, then
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
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
clinical colleagues. Response to this being pointed out has been
unsatisfactory but we are assured it won't happen again. "Payment by
may remove one driver to this practice, when there is specific payment for

secondary referrals, but waiting time targets do not include these
and will probably carry more important consequences.
"Choose and Book" will alter the problem. In the preparation I have had
this, such as it is, it was only the consultants that realised we had to
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
using the GP as a relay. I'd have no problem with my referrals being
scrutinised by other clinicians for clinical appropriateness, providing it
delay the appointment for the patient. In the change of systems around us
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
from consultants are to take lower priority then this needs to be explicit
a system agreed whereby referrals from consultants are considered and
forwarded by primary care, to ensure that referral and treatment is based
clinical need.

Competing interests:
None declared

Competing interests: No competing interests

16 February 2006
Lesley J Kay
Consultant Rheumatologist
Freeman Hospital, Newcastle upon Tyne, NE7 7DN