Referral
Dr Lau Pui Lam Patrick
KCC/H1
Definition of referral
McWhinney
A transfer of responsibility for some aspect of the
patient’s care
The family physician always retains an overall
responsibility for the patient’s welfare
Rakel
A transfer of responsibility to another physician for
the care of a specific problem
Agents of referral
GPs/ family physicians with special interests or
expertise
Allied health professionals – community nurse,
social worker, physiotherapist, dietitian
Social agencies – NGOs
Hospital consultants – outpatients/ inpatients
Types of referral
Interval referral
the patient is referred for complete care for a
limited period
Collateral referral
the referring physician retains overall
responsibility, but refers the patient for care of
some specific problem
Types of referral
Cross-referral
the patient is advised to see another physician,
and the referring physician accepts no further
responsibility for the patient’s care
Split referral
responsibility is divided between two or more
physicians
Reasons for referral
Specialist treatment – e.g. surgery
Specialist opinion on diagnosis and/ or management of a
difficult problem
Gain access to certain diagnostic and therapeutic facilities not
available outside hospital – e.g. OGD, colonoscopy, fiber-
optical nasolaryngoscopy, PTA
Multidisciplinary care
Reinforcement of advice given to a poorly compliant patient
Patient request for 2nd opinion
Sharing the load of a difficult or demanding patient
Avoidance of malpractice complaint
Reassurance for the patient (or doctor)
Getting rid of the patient
Referral process
Define and specify the need and purpose of referral,
including mutual understanding between patients and
physicians
Adequate communication of purpose to consultant
Attention to purpose by consultant
Adequate communication of findings and recommendations
to the referring physician
Clear understanding by patient, referring physician, and
consultant of responsibility for the patient’s continuing care
Williams et al , 1961
Factors affecting referral
Referral is a very complex process
Incompletely understood
Wide individual variation
Interplay of doctor, patient, illness and context
Explanations are difficult even when medical
education, socio-demographic features, morbidity
are controlled
Factors affecting referral
Studies:
Netherlands – distance from hospital and doctor’s
attitude to defensive medicine weakly associated
with referral rates
15 European countries – strong inverse relationship
between referral rates and number of doctor-patient
encounters
Factors affecting referral
Relationship between higher referral rates and
doctors’ lack of self-confidence and defensiveness
High referrers were more likely than low referrers to
refer despite doubts about usefulness of referral
More uncertainty about decision making among high
referrers
Problems of referral
“collusion of anonymity” (Balint 1964)
many specialists see a patient but no one accepts
overall responsibility
Fragmentation of patient’s care
Problems of referral
Refer or not refer?
Inappropriate referral
unnecessary investigation & treatment
Burden to health care system
Under referral poor health
Problems of referral
Poor communication between referrers and
consultants
Dissatisfaction
Lack of information about discharge and follow-up
plans
Referral guidelines
A means of improving appropriateness of referral
? Change in behaviour
Referral rate not drop accordingly (may rise)
Study in Scotland: guidelines for infertility referral
“increased investigation done before referral, improved
appropriateness”
Subsequent studies: “no overall benefit to patient”
Areas of improvement
Remain the focus of referral to avoid fragmentation
of care
Acting as a reference point, coordinators and source
of information and explanation
Good communication between referrers and
consultants
Making a better referral
Responsibility of the referring physician
The consultation process
Selection of appropriate specialist
Adequate transfer of information
Patient preparation and compliance
Evaluation of information
Feedback to specialist