Abstract
One of the regular tasks of a GP is to refer patients to secondary care and allied healthcare teams. Good quality referrals allow appropriate triage and are essential to smooth functioning of the speciality service. Ambiguous referrals on the other hand can often put the patients at risk, as well as burdening the service. In the following article, Dr Kunal Chawathey discusses the rationale behind referrals and provides useful tips to write high-quality referral letters.
An important role of the GP is one of problem recognition and decision-making. Having said that, even the most broadly experienced clinician would struggle to single-handedly manage the vast variety of pathology encountered by GPs. A key aspect in the training of generalists is effective risk management, stratifying patients based on the significance of their signs and symptoms and referring them appropriately.
Why do GPs refer?
About one in 20 GP consultations result in referral to another service, making referral an important driver of cost to the NHS. Understandably, referrals are under constant scrutiny – a clinical commissioning group (CCG) recently classified GP referrals as appropriate, inappropriate, too early or ‘bonkers’ in their commissioning audit! Referrals are made for various reasons: To establish a diagnosis, for investigations not available in primary care, for treatment or an operation, for advice on further management and occasionally for reassurance. Patients may view their GP as an obstinate gate keeper to secondary care and sometimes demand to be seen by a specialist for trivial symptoms – increasing the number classified as ‘inappropriate’ or ‘bonkers’ in any commissioning audit!
The GP’s dilemma
Diagnosis in primary care is made more challenging by the undifferentiated nature of symptoms, the weak predictive value of available diagnostic tests, a high degree of overlap in symptoms between common, trivial conditions and uncommon, serious diseases and the high prevalence of medically unexplained symptoms. Also, primary care clinicians regularly deal with slightly abnormal results in asymptomatic patients. Is this a normal aberration or the early presentation of disease? A question, often not easy to answer.
Furthermore, the principle of diagnostic parsimony, or Occam’s razor, is not always applicable in primary care. Consider a patient presenting with unsteadiness of gait. On examination, he has absent knee jerks and up-going plantars. In a neurology clinic, the quest for a unifying diagnosis may generate differentials ranging from motor neuron disease, multiple sclerosis to a conus medullaris lesion and Friedreich’s ataxia. In the primary care setting, however, the more prevalent presentation would be that of a dual pathology, i.e. diabetic neuropathy plus cervical myelopathy. As a GP you could request a magnetic resonance imaging (MRI) scan of the cervical spine, but are unlikely to have access for specific tests to rule out (or rule in) the differentials.
What makes a good referral
There is no single agreed definition of a high-quality referral. The key factors to bear in mind when making a referral are necessity, urgency, destination, process and information. Pure clinical need is not the only criterion that needs to be satisfied to make a referral. A referral may still be justified in terms of providing reassurance to the GP or patient, and the requirement for reassurance will vary from one GP or patient to the next (Blundell et al., 2010). Furthermore, there may be circumstances where refusal to make a referral can damage the GP–patient relationship. Some practices make a policy of discussing referrals at clinical meetings to ensure they are necessary and prioritised appropriately. As a GP trainee, discussing referrals with your supervisor is an invaluable learning opportunity.
Most speciality service providers have urgent referral pathways to ensure that serious conditions are dealt with swiftly. It is important for GPs and GP trainees to be well acquainted with the referral criteria for these presentations. When new to a practice, I recommend a thorough review of all the 2-week wait (2WW) referral forms within the first month of placement.
It is important to determine the correct destination for your referrals to avoid, for example, unnecessary interdepartmental transfer of the referral. Avoid being the frazzled new trainee who refers a patient with nephrolithiasis to nephrology rather than urology! With increasing sub-specialisation in secondary care, finding the right specialist can be difficult. I remember a GP trainee referring a baby with a strawberry nevus at the lower lid margin to ophthalmology, blissfully unaware that oculoplastics department at the tertiary eye centre offered beta blocker therapy (as opposed to the traditional ‘watchful waiting’ or surgery) for such lesions.
Pre-referral management
A high-quality referral depends not only on the referral itself, but on what happens in primary care before the referral. Especially in non-urgent situations, it is important to ‘work up’ the patient, performing relevant examinations and investigations prior to referral.
The referral letter and the SBAE format
High-quality letters serve as an effective medium for communication between primary and secondary care. The content of a referral letter will vary depending on the individual situation. A good referral letter needs an accurate and succinct history, conveying your ideas, concerns and expectations. Try adapting the SBAR (situation, background, assessment, recommendation) format used in handovers to an SBAE structure for referrals, where the letter E stands for expectations. Have a look at the sample referral letter below.
Scenario
A patient with worsening prostatic symptoms requires urology referral for further management.
‘(Situation) I would be grateful if you could see this 70-year-old gentleman with prostatic symptoms, worse over 6 months, with a view to surgical intervention.
(Background) He has a background of Type 2 diabetes, well controlled on metformin.
(Assessment) He has been taking tamsulosin regularly for the last 2 years, but has complained of worsening urgency, hesitancy and nocturia (3–4 times at night) over the last few months. There is no history of urinary retention, recurrent infections, haematuria, weight loss or back pain. He has not benefited from finasteride added 4 months ago. He is not on any other medication and has no known allergies.
Mr Smith is a non-smoker and drinks 6–8 units of alcohol per week. He lives with his wife who is fit and well.
On examination, blood pressure was 130/80 mm of Hg. He did not have a palpable bladder. Digital examination revealed a smooth, enlarged non-tender prostate.
His Prostate Specific Antigen (PSA) is 5 with no recent increment, estimated glomerular filtration rate (eGFR) is stable at 80, Glycosylated Haemoglobin-A1c (HbA1c) is 51. Other results are attached with the referral.
(Expectation) Given worsening symptoms despite dual therapy, I wonder whether he would be a candidate for operative intervention. Mr Smith is keen to consider surgery to ameliorate his symptoms.’
Is there anything else you might add to this letter?
As an exercise, you may also wish to discuss with your trainer/trainee, the relevance of the pieces of clinical information provided in aiding decision-making at secondary care level.
Note that one important piece of information was missed out in an otherwise excellent letter, i.e. a urine dipstick result.
What vital information could be gained from urine dipstick examination in this case?
Top tips for making referrals
Ensure that the referral is necessary, discuss with your trainer if in doubt Acquaint yourself with the local 2WW referrals criteria Check that you are directing the referral to the appropriate speciality (or sub-speciality) Ensure that your referral letter conveys all the necessary information Do the appropriate work-up prior to the referral Trainees should keep a record of their referrals and follow them up for further learning
Tips for writing referral letters
Ensure that the referral is appropriately prioritised and includes adequate contact information Have a structured format to the referral Mention relevant positive and negative history, including red flags Include an up-to-date assessment of the patient, including current symptomatology, examination findings, medications and recent investigations Mention relevant psychosocial details, especially in elderly care referrals Mention relevant interventions carried out in primary (and secondary) care to date Explain your own (and the patient’s) concerns and expectations of the referral
Despite best efforts, you may end up referring to maintain the GP–patient relationship. In such situations it is useful to outline discussion of the condition or treatment and detail the patient’s unmet expectations and level of concern prompting referral.
Referring a patient for further care is often a complex decision reached after much thought and deliberation. Learning to express this process succinctly through referral letters is a skill that takes time and practise.
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