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How to… deal with referral management centres

Dr Nicholas Norwell explains how to avoid the pitfalls of referral management

Some primary care organisations (PCOs) use referral management centres (RMCs) to monitor, direct and control referrals from primary to secondary care and other services. Their main function is to receive and analyse data on GP referrals but some also decide the best treatment route. This may involve sending referrals to a specialist chosen by the referring GP, to a different specialist, to a GPSI or to a nurse specialist.

However, the RMC may send the referral letter back to the GP if it is deemed inappropriate or that the problem can be dealt with in primary care.

Patient safety
One of the main ways RMCs could benefit patient safety is in providing a service to track GP referrals. In the Medical Defence Union’s experience, delayed diagnosis is one of the most frequent reasons for a claim being made against GPs. Often the delay is not due to clinical error but a failure to track the patient’s progress after referral.

Another advantage is the appropriate redirection of referrals (if, for example, an alternative specialist can provide a more convenient appointment for the patient) and the analysis of referral patterns. The latter can be used to target resources more specifically and for GPs’ continuing education.

Medico-legal risks
However, some GPs worry about their responsibilities when their referrals are directed via a RMC, particularly about patient confidentiality, and who would bear responsibility if the RMC caused a referral to be lost or delayed.

Other problem areas are the patient being seen by an inappropriate specialist, returning the referral to the GP when it is, in fact, needed and whether the RMC handling of the referral may breach patient confidentiality.

Patient confidentiality
GPs should tell patients that their referral letter will go via a RMC. In Paragraph 16 of its booklet Confidentiality: Protecting and Providing Information (2004), the GMC states: ‘Express consent is usually needed before the disclosure of identifiable information for purposes such as research, epidemiology, financial audit or administration.’ It also says that when seeking express consent to disclosure, the doctor must make sure that patients are given enough information on which to base their decision including the reasons for the disclosure and the likely consequences of the disclosure.

The doctor should also explain how much information will be disclosed and to whom it will be given. If the patient objects to information disclosure, the GP should respect their wishes and make the referral directly to the consultant. However, GPs should be able to rely on the standard of confidentiality at the RMC to be comparable to their own.

Lost or delayed referrals
GPs are responsible for making an appropriate referral, for indicating its urgency and for ensuring, as far as possible, that the referral reaches the RMC. It is responsible for dealing with the referral once it reaches the centre.

However, if a complaint or claim arises because of a delay caused by the referral process, much will depend on the individual circumstances. The GP could bear some liability if the urgency of a referral was not indicated — or if a referral marked urgent failed to reach the RMC and the GP did not realise this.

The GP might bear some liability, too, if the referral is lost or delayed and the GP does not act on that information.

Track your referrals
For the above reasons, it is advisable for GPs to have a system in place in their practice for tracking referrals. For urgent referrals, GPs may decide to follow them up themselves if they have heard nothing within a certain period.

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