ANALYSIS:For the health system to work safely, a senior doctor must review incoming GP letters within 48 hours at the very least, writes DR MUIRIS HOUSTON
DESPITE TALLAGHT hospital’s admission that there is a smaller batch of unopened referral letters from GPs to its consultants than originally estimated, the concerns raised by Prof Tom O’Dowd remain valid.
His letter to the chairman of the hospital, where he outlined a threat to patient safety, referred not just to unopened referral letters but also to letters from family doctors that had not reached consultants.
We now know there were some 3,498 letters that had not been reviewed by a consultant in October 2009.
Why is this such an important issue? The referral of a patient from primary to secondary care is at the core of our health system. It frequently involves a decision by a GP that a patient he has seen has either symptoms or clinical signs suggestive of serious illness such as cancer or heart disease. The next step is to write a referral letter to the appropriate consultant in an acute hospital.
In this case, the doctor will label the referral urgent and will detail why he thinks the person needs prompt investigation. The consultant reviews the letter and arranges for a confirmed appointment to be sent to the patient.
For the system to work safely, a senior doctor must review incoming letters on a regular basis and certainly within 48 hours of receipt. And regardless of urgency the patient should hear back from the hospital within 14 days with a firm appointment date. If these parameters are exceeded, the potential for unnecessary error and patient harm increases.
An example of how the system should work is evident from the St James’s Hospital, Dublin, website which states: “As part of St James’s commitment to quality and the patient’s charter, we continue to strive for improvement in the quality of communication systems and response times in dispatching outpatient appointments. To assist the hospital in achieving these aims we request that GPs/external consultants referring patients to any of the services follow [set] procedures”.
The hospital goes on to say that referrals to a particular speciality will be prioritised and an appointment will be made with the appropriate consultant.
The instructions clearly specify how to deliver a referral letter to St James’s: this can be by post, by hand to the outpatient reception desk or by electronic means.
The website contains the following assurance: “All referral letters upon receipt are prioritised by the consultant or senior registrar as to whether the patient is seen as an urgent, soon or routine appointment.”
In addition, the website states that it is hospital policy to contact patients with an appointment within 10 working days of receipt of a referral letter.
A good referral is one that sends the right patient to the right service or specialist at the right time. It must contain sufficient information to allow the hospital consultant to assess its urgency and relevance. GPs refer patients to specialist outpatient clinics for a variety of reasons.
These include: referral for diagnosis or for an investigation that cannot be done by the GP; referral for advice on the best means of treatment for the patient’s condition; referral for the specialist to initiate a course of treatment; and referral for second opinion or to reassure the patient.
If every acute hospital in the Republic operated a referral system as streamlined as that of St James’s Hospital, then we could be reassured that the problem is confined to Tallaght hospital. Unfortunately we cannot say with certainty that this is the case.
What is now required is for the Health Information and Quality Authority (Hiqa) to assess the performance and integrity of the referral process in each of the country’s acute hospitals.
Its report must specify how a referral letter works its way through the hospital system, whether and how soon a senior doctor reads it and the timeframe within which a patient receives a date for an outpatient appointment.
Until such an exercise is completed, it will not be possible to completely reassure patients the referral process is safe throughout the State.