One continuing concern for GPs during the COVID-19 pandemic has been the delay in patients being seen for non-COVID-19 issues once a referral has been made to a specialist.
Here are some steps to take to avoid patients coming to harm while putting yourself in the best position to address the potential medico-legal ramifications.
Managing patient expectations
In its guidance on Delegation and referral, the GMC says that you are not accountable for the actions or omissions of colleagues to whom you make referrals, however, you are accountable for your decisions to transfer care and the steps you have taken to make sure that patient safety is not compromised.
If you're aware there are delays for a particular service and your patient is likely to be affected by this, you should make this clear to them and manage their expectations from the outset.
Below are some actions you can take.
- Ensure the patient understands whether the referral is urgent or routine and the timescale you expect for an appointment. Ask them to get in touch if they do not hear anything by that time.
- Provide safety netting advice to the patient so that they know what to do if their symptoms deteriorate before their referral is actioned.
- Discuss alternatives with the patient, for example, their thoughts on a private referral.
- Discuss with the patient any sensitive information that you plan to include and explain why it is clinically relevant to do so. If the patient refuses to consent to you disclosing information, explain the risks associated with this.
- Ensure you make the urgency of the referral clear. For urgent referrals, highlight the relevant clinical detail to avoid this being relabelled as a routine referral if triage is carried out.
- Include all relevant clinical details including the patient's history, medication, allergies, examination findings and details of any investigations.
- Ideally, type referral letters if they are not being sent electronically, but if handwritten, ensure writing is legible.
- Sign and date the letter, include your contact details and retain a copy in the patient's medical records.
- Report any deterioration or new symptoms to the person or department you have referred the patient to. Inform them about any updated investigation results.
- Consider if further care can be offered in the interim, for example, by discussing the patient's condition with the health professional you have referred the patient to.
- Consider putting a practice policy in place so that patients who have been referred, where you know there is a long waiting time, are reviewed and the progress of the referral monitored.
- Ensure continuity of care if you're no longer available or are due to leave the practice. Hand over to another clinician, making them aware of the referral and the patient's condition.
- Discuss any specific concerns with your Local Medical Committee while protecting patient confidentiality. If you are experiencing difficulties, it is likely that other practices in the area are as well.
- Investigate any complaints in the usual way, offering an apology where appropriate and providing the patient with an explanation and informing them of any learning points that have been identified. See our full guidance on dealing with complaints.
- You have a responsibility to raise concerns if you think that patient safety is or may be seriously compromised.
Get advice from us if you face criticism as a result of a delayed referral or if you're concerned about the impact on safe patient care.
The following case is fictitious but based on the types of cases that could occur.
A 70-year old man consulted his GP during the height of the COVID-19 pandemic remotely by video. The patient had been suffering from urinary symptoms for some time, including frequency and hesitancy. A PSA carried out about three months earlier was normal. The patient was otherwise well, with no weight loss or pain, but had an episode of frank haematuria. The GP noted he suffered from urinary tract infections in the past and prescribed antibiotics. However, due to this new symptom, she also referred the patient urgently to secondary care under the two-week-wait rule.
After three weeks the patient still hadn't received an appointment and had a further episode of haematuria. The GP rang the urology department to try to expedite the appointment. Many staff at the hospital had been redeployed to assist with the pandemic and clinics had been cancelled. The trust was also experiencing staff shortages due to sickness. The GP apologised to the patient for the delay and provided safety netting advice. The patient was offered the option of a private referral which he declined.
By the time the patient was seen, eight weeks had passed and he had now begun to lose weight and experience back pain. He was diagnosed with a renal cell carcinoma and later made a complaint to the practice about the delayed referral.
With the help of the MDU and her comprehensive notes, the GP explained what actions she had taken to speed up the patient being seen as soon as she became aware of the delay. The GP apologised again, explaining the difficulties caused by the pandemic. The patient was satisfied with the response and accepted that the GP had done all she could in the circumstances.
A version of this article first appeared in GP online.
This page was correct at publication on 04/04/2022. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.