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Practice dilemma: Should we track our urgent referrals?



In May, it emerged that hundreds of patients with suspected cancer referred by GPs to Imperial College Healthcare NHS Trust may not have been seen within two weeks because of ‘data-collection’ issues. London GPs were asked for their help in tracking patients; a report subsequently found that no patients had come to harm. But after this blunder, we’re concerned about urgent referrals getting lost. We just don’t have the time to chase up every possible cancer case. How much responsibility do we have to make sure urgent referrals go through the system?

At the GP/hospital interface, one of the potential communication risks is that of patient referrals. Although we can be more confident that electronic referrals from general practice are received in secondary care compared to the traditional paper-based standard, the systems are not foolproof. The recent case at Imperial College confirms this concern.

What, therefore, are the GP’s responsibilities once the referral has taken place? And what can be done to minimise risk?

Take this case study: a 60-year-old man was referred to a dermatologist for the assessment of an irregular, discoloured skin lesion on his chest. He was seen as an outpatient and listed for a biopsy, which duly took place. A discharge letter was sent to his GP indicating that he would be seen in six weeks at the outpatient appointment when the pathology results would be available. Unfortunately, the outpatient appointment was never organised and any chance of a reminder in the form of histology results was also lost, when these were not reported to the dermatologist.

More than a year later the patient presented again to his GP with dyspnoea and metastatic malignant melanoma was subsequently diagnosed.

The patient died four months later and his wife understandably questioned his management. The dermatologist, GP and pathologist were all criticised for what was identified as a systems error and a payment was made.

This case illustrates that there are pitfalls beyond the stage of the referral being made and received. It describes a delayed diagnosis of cancer, which may lead to substantial damages, depending on the harm done and the specific circumstances of the claimant.

Reducing risk

There are no easy solutions and it would be counterproductive to suggest a system that is unduly work-intensive for GPs. To implement a belt-and-braces system for all referrals would be a retrograde step.

Nevertheless GPs can be vulnerable, should the referral system fail, and the stakes are of course high with cancer referrals. 

There are some commonsense options, that can be used to proactively track urgent referrals for suspected cancer.

GPs could, for example, consider advising patients: ‘If you don’t receive an appointment within two weeks, get back in touch with me.’ Recording this in the notes at the time of the consultation would be beneficial.

Some practices keep a log of urgent cancer referrals and if they are not able to tie up the referral with a response, they check with the patient that an appointment has taken place. Where this can work well is in the form of a spreadsheet, where urgent cancer referrals are logged once sent. GPs may delegate responsibility to a receptionist to check on a weekly basis whether these have been actioned.

Referrals, particularly urgent referrals, have been streamlined by electronic transmission. Unfortunately the system is not foolproof and additional checks are recommended for suspected cancer referrals.

Dr Andrew Power is a medicolegal adviser for the Medical Protection Society