Approximately one in a hundred people who consult a general practitioner is referred to a specialist. There isn’t an exact number because some GPs will refer more often, either because they have more patients who need referral or because they need the additional support themselves. Whatever the reasons the demand for specialist appointments is increasing; more people are diagnosed with cancer, dementia, diabetes and depression. More people are surviving life limiting illnesses and joining long queues in outpatient clinics. At the same time there is enormous pressure to contain healthcare costs. So in the name of ‘safety, quality or efficiency’ healthcare providers are reigning in expensive healthcare interventions and access to specialists is on the list. That means there is a growing incentive to ‘prioritise’ those who are most likely to benefit from attending specialist clinics- those who are at highest risk of having a life threatening illness and especially those who are most likely to benefit from earlier treatment. There is pressure to ensure specialists are employed to serve new patients with serious illness and spending less time on matters that can be delegated to someone else.
In this context it is a feature of many healthcare systems that the specialist is requested to assist via a letter from his or her colleague in general practice. The GP is in fact the ‘gatekeeper’ to those services, this is especially true of those services that are subsidised or wholly funded by the tax payer. So what that letter says determines how quickly the patient will be seen because someone, often the specialist will schedule an appointment based on the contents of that letter. Of course it is still possible that a the doctor in the community might pick up the phone and call his specialist colleague if he was concerned that the patient needed urgent attention. Nobody really knows how often that happens. It is also possible that the patient may opt to see the specialist at a private clinic and, as would be the case in my country, be seen within a week.
In any case the ‘referral letter’ is an important element of the patient’s trajectory through the system and here are some inconvenient truths:
- Doctors are not formally taught how to write referral letters and there is evidence that such letters can be improved.
- The letter may be ‘triaged’ by a specialist, a nurse or a clerk.
- Doctors don’t generally think there is anything wrong with their letters, or that their colleagues read those letters and everyone has a different idea about what they should contain.
- We know specialist often say that GPs don’t write enough detail in their letters.
- We also know that some people don’t think it’s worth spending time and effort focusing on referral letters because one day the process will be superceded by technology- it hasn’t happened yet and doesn’t look like it will happen soon.
Exploring, let alone improving referral letters is fraught with challenges:
- GPs are not paid to do research and therefore are loath to spend precious consultation time recruiting and consenting patients for access to their records at a time when the patient might be facing bad news.
- GPs are ambivalent about testing tools to improve their letter writing skills unless those tools are incorporated into their existing clinical software system.
- Software developers won’t ‘waste’ time incorporating such innovations until they have proven value.
- Doctors also argue that there is nothing wrong with their letters and that they record a lot of the relevant clinical details in their records. In fact, they don’t.
- Specialists may be reticent to be involved in the research in case it sullies relationships.
Twelve years and several small or unfunded studies and some false starts later we are able to report on what we believe is the first randomised controlled trial examining the impact of GP referral letters on potential outcomes for patients. We were surprised by the results. The paper is in press and I look forward to sharing it with you soon. Suffice it to say that we still think it is an important issue, especially because most cancers are now diagnosed from people with symptoms who consult a generalist and because there are more, not less people in need of urgent specialist care. What’s more we have developed an innovation that just might work.