Julie Baylis, case manager at Medical Protection, answers a common query about an e-referral system

“I am a GP and the practice I work at uses an e-referral system. When the practice submits a referral using this system, we receive an acknowledgment notification to indicate that this referral has been ‘delivered’. Once the referral has been processed by the hospital, we would receive a further notification to indicate that some action has been taken by the hospital, such as an appointment has been arranged, or the referral has been passed to the appropriate person.

“However, we have recently experienced delays in receiving the second notification from the hospital. This means that the referral sits in our practice system as ‘overdue’. Meanwhile, we receive calls from patients seeking the status of their referral and querying when their appointment with the hospital will be. I am concerned as many of these patients have serious conditions and may be impacted significantly by this delay.”

The GP was concerned about the practice’s obligations to follow up on these referrals and any medicolegal risks that the practice might be exposing themselves to. She contacted Medical Protection for advice.

Expert advice

In their Guide to Professional Conduct and Ethics for Registered Medical Practitioners[1] the Medical Council provides guidance on referral processes as well as the delegation of the care of a patient. The Medical Council acknowledges that referrals are made for the purpose of obtaining an opinion or treatment from another doctor or healthcare professional. This referral will usually involve the transfer (at least in part) of responsibility for the patient’s care as a ‘handover’.

The Medical Council advises: “When you hand over care for a patient to another healthcare professional, team and/or institution, you should check that they understand and accept responsibility for the patient’s care. You should pass on all the relevant information about the patient and the patient’s care. When discharging patients back to primary care, you should give all relevant information promptly.”

When referring patients to secondary care for an opinion or treatment, it is important to bear in mind that the Medical Council is likely to consider that the patient’s overall management will remain under the “supervision and guidance of a general practitioner”. In relation to the transfer of patients to another doctor or service, the Medical Council advises: “Until care is taken over by another doctor or service, you are responsible for your patients.” This advice would appear to be applicable to a potential delayed referral scenario.

Taking the above into account, it is clear that a GP does have an enduring responsibility for patient care, even after a referral has been made. Just because a GP has referred a patient to secondary care, it does not mean that their responsibilities and obligations to the management of a patient’s health are reduced. This is particularly pertinent in the situation the GP has described here.

When handing over the care of a patient, the GP should check that the person(s) to whom they are handing the responsibilities for the care understand and accept responsibility for the patient’s care. It is also important to ensure that any referrals contain the information that would be expected such as the urgency, any red flag indicators and adequate clinical information, to allow for the referral to be assessed appropriately.

From a practical perspective, the GP should consider contacting the hospital or place of referral after a certain length of time, to check that this referral has been received and acted upon, as part of the continuing obligation to a patient’s health management. Checking that a referral has been acted upon is a prudent safety net measure. Such action would assist in mitigating the exposure of a GP to medicolegal risks arising, such as a claim in relation to a delayed referral for an alleged injury or a complaint to the Medical Council. The exact interval of contact would depend on the clinical issues that are at hand. For example, an urgent suspected cancer referral would need to be followed up promptly if a practice felt that it wasn’t receiving suitably urgent attention.

Practices should ensure that a record is kept of any steps that are taken to follow up on overdue referrals. Doing so may assist in reducing any potential liability that may fall to the GP in the event of a claim arising.

Learning points

• When making an urgent referral, the referral letter should contain the expected clinical information to ensure the receiving clinician or triage service understands the level of urgency.
• Practices should have a system that allows them to view/access a list of overdue referrals that may require review or further action by the practice, to ensure that a referral has been received and acted upon.
• GPs should be aware of their continuing obligations and responsibilities, as set out by the Medical Council, when referring, delegating or handing over any aspect of a patient’s care.
• Individual GPs may wish to keep their own log of patients referred, so that they can ensure that the patient has received care within an appropriate period of time. This may serve as an opportunity for learning too.