Five GP referral systems – four of them safe

There are now five ways a GP can refer a patient to a hospital and a problem that needs to be solved.

1. Advice and guidance
2. Referral and advice service
3. Two week referrals for cancer
4. Paper referral to a named consultant and/or their team
5. Electronic referral service (traditional choose and book)

Advice and guidance

This enables a GP to refer a patient for advice and 80 per cent have to be responded to within two working days. This, conceptually, is a brilliant way of getting fast real time advice and stops patients having to wait weeks and sometimes months to get help.

This, in turn, significantly reduces the need for them to attend outpatients and all the add on pressures that entails, particularly the frail where a 10 minute appointment starts with a pick up by hospital transport in the morning, hanging around for hours, variable food provided and being taken home, sometimes late in the day.

A modified example of this is the new renal service at Barts. A GP refers for advice and guidance via the traditional eRS method into a “virtual appointment slot”. This then typically comes back within one working week, with the consultant writing remotely into the GPs clinical notes and able to see all the GPs consultations and investigations within the primary care system.

This has reduced patient attendance at outpatients by 80 per cent and is really valued by patients and GPs, as it is real time help and advice. Patients with renal disease can often be attending other outpatients and in the wait to be seen can significantly deteriorate. This is both safe and a great experience for patients and GPs.

This, conceptually, is a brilliant way of getting fast real time advice and stops patients having to wait weeks and sometimes months to get help

A by product of this is that the renal team has set up an early warning artificial intelligence system, which warns GPs of any significant deterioration in renal function. This also enables potentially an enormous research opportunity to answer the question, which patients will deteriorate rapidly and need renal dialysis or transplant and how that can be prevented.

One of the main reasons that we had to use a modified system for advice and guidance locally is that the down side of the provided advice and guidance national IT system is that it is very clunky and old fashioned. It is not easy to transfer anything more than a simple question and then get a simple single response back. It also does not easily allow the transfer of full referral letters, such as used in the usual eRS system.

If the consultant under this system thinks a patient should be seen in outpatient or have hospital tests, they will then write back to the GP asking them to do a formal referral as there is no possibility of an onward referral via the built in A&G. Rather a waste of everyone’s time.

RAS

This new system was developed by NHS Digital after approaches to them by Tower Hamlets Clinical Commissioning Group and this method incorporates the best of the traditional choose and book system with the flexibility of advice and guidance as well as allowing the learning curve to be very easy as it is the same referral methodology and clinical integration as the current eRS (choose and book) pathways. 

A referral letter can be transferred by the eRS system immediately to a consultant and their team for immediate clinical triage. They can choose a whole raft of different options – ring or potentially Skype the patient, bring them in for an investigation, give management advice to a GP or the patient (one of the consultants has come up with a brilliant innovation – the letter goes back to the patient and is copied to the GP rather than the other way around).

This method incorporates the best of the traditional choose and book system with the flexibility of advice and guidance

They can also choose to book them into the most appropriate outpatient clinic. This system ensures immediate triage by a clinician and that the patient either gets real time advice or gets to the right test or specialist in the right time and in the right place.

This, like the above, will lead to significant reduction in the wasting of patients’ time and, therefore, improved patient experience, but in some ways more importantly ensure timely and safe clinical specialist management.

Fast track referral pathway for cancer

This is a brilliant, timely and safe system for patients and GPs. It also has standardised referral forms, which continually educate GPs and drive up the quality and appropriateness of the referral.

In Tower Hamlets, we have now also developed similar referral forms for all specialties and have the ability to improve and update them overnight, changing them remotely in every GP surgery. This will greatly improve the quality of the referral and the ease of triage by the consultant and their team.

Paper referral to a named consultant or their team

This gets around the clunkiness of the advice and guidance system and ensures all the advantages of RAS listed above, but not ideal as from the GP side we have gone almost completely paperless. Also, it does not provide a clear electronic audit trail, which can hold the hospital and specialist to account for waiting times. All the above systems though do bring back clinical triage and accountability.

eRS (traditional choose and book)

A GP will be seeing a patient typically in a 10 minute appointment and be doing investigations, but will reach a point where they require expert support or access to investigations that are only possible through a specialist.

They go on to the eRS (choose and book) system and virtually the only information available is around the waiting time. Nothing about the quality of the service and no detailed comparative information about the service provided.

An appointment is booked for a patient to be seen in outpatients weeks and sometimes months later. In theory, there are urgent appointment slots, in reality the wait is often very similar to the non-urgent wait.

Weeks later when the patient is seen by the specialist, the referral letter will be read for the first time. Tests will often be repeated and it is not unusual that a consultant will refer on to a more appropriate specialist.

Choose and book has been dubbed choose and forget by our local GPs and is clearly seen as unsafe for patients compared with the modern alternatives

Any opportunity to avoid a patient having to come into hospital has been missed, the disease has progressed in the few weeks and months while waiting for the appointment and for those many patients with a number of chronic diseases, the advice might have been superseded by a visit to another specialty team. Relative to the other systems, this is now UNSAFE.

Average cost of seeing a GP: £15-25

Average cost of outpatient attendance according to my finance director: £624

We believe we could reduce outpatient attendance by 50 per cent and go back to what it was 10 years ago. Cost saving, improvement in patient experience and safer medicine?

Choose and book has been dubbed choose and forget by our local GPs and is clearly seen as unsafe for patients compared with the modern alternatives.

The problem

Many hospitals are seen putting the option of advice and guidance and RAS as optional unlike the target to achieve 100 per cent electronic referrals by October 2018.

This is a very big missed opportunity to improve the safety of the system, take significant pressures off the acute and primary care systems, finances and workload, and greatly improve the patient experience.