Dr V was working for three days as a locum in a busy general practice. She had not worked there before and the job was arranged at short notice.
On her final day she saw a 35 year old mother of two who had just noticed a breast lump in the shower that morning. She was understandably anxious, and wanted to be seen as soon as possible. She asked about paying to go privately, but Dr V assured her that she would refer her as a “two week urgent referral” and that she would be seen within that time frame.
Dr V dictated the referral at the end of her session and asked to secretary to ensure that it was sent urgently. She left the practice and thought no more about it.
Six weeks later she received a telephone call from the practice manager. The patient had just been back to see her usual doctor, as she had not received word from the hospital. It transpired that, for some reason, the referral had not been received by the hospital.
Subsequently the patient was seen at the hospital. She was diagnosed with and treated for a breast cyst.
She did ask the practice to look into how the incident had happened, as she was keen to ensure that other patients did not go through similar experiences. Investigation revealed that the secretary had typed the letter and placed it in the “locum” pigeon hole. Since there had been no further locums since Dr V, the letter was still there.
This case highlights that there are potential pitfalls for locum GPs when undertaking referrals for patients. Even if referrals are handed, in person, to the practice secretary, as in Dr V’s case, there may still be the risk that a referral is missed.
Medical Protection conducted 107 Clinical risk self assessments (CRSAs) in general practices in 2014. In 57% of these practices there were risks identified with the referral system. Risks included:
- No clear referral protocol
- Different referral practices for different doctors
- Staff unfamiliar with the referral process
- Letters dictated but not signed
- Dictation tapes being lost
- Delay in dictating letter
- Letters not being dictated
- Referral letters “lost in post” to hospital
- Referrals being received by hospital but appointments not being received by patients
- Patients not encouraged to contact practices if appointments not received
What can locum doctors do to reduce this risk?
The most important thing that locums can do to mitigate this risk, as well as others, is ensure that they are fully aware of the way the practice works and its processes, prior to commencing their post.
All locums should ask to see the practice’s induction pack prior to their first surgery.
All locums should ask to see the practice’s induction pack prior to their first surgery. This pack should include details of the referral process including:
- Telephone numbers and email addresses for the relevant hospital departments.
- How to make emergency, 2 week and routine referrals.
- How to undertake dictation.
- Named members of the administration team who deal with referrals.
- A copy of the practice’s referral protocol.
In the past 15 years the NASGP’s Standardised Practice Induction Pack (SPIP) has been used by over 3,000 practices. This pack provides a format for practices to provide the information that locum GPs need to successfully and safely treat patients, even if they have never worked in that practice before.
NASGP have recently launched the online version of SPIP. The online benefit is clear - locum GPs can familiarise themselves fully with the practice before they even set foot in the building. Locums may wish to advise practices of this excellent resource, especially if they feel the practice’s induction pack is inadequate.
- When dictating letters, ask the secretary to type it up that day and ensure you sign it before you finish your session.
- If the referral letter cannot be typed that day, “hand over” the referral to one of the GP partners, asking them to sign and send the letter when it is typed.
- Tell the patient that you are a locum doctor, and ask them to contact their regular GP if they have not received an appointment within the expected timeframe.
- Timeframes do vary, but by involving the patient in this way, it may reduce the risk of a referral being missed.
- Find out if the practice is set up for electronic referrals. This is available in many parts of the UK now and reduces the risk of referrals being missed.
- If electronic referrals are possible, do your referrals electronically yourself, as you can then be sure that the referral is typed and also received at the hospital.
- For two week suspected cancer referrals, always ask a named GP to follow this up, to ensure that the patient receives an appointment and is seen. ●
Do you get your own username and password when signing into practice computers? Sick of always being signed in under various combinations of ‘LOCUM1/DRL/LARRYLOCUM’? Perplexed as to how it’s your first time at the practice but looks like you (DRLOCUM) have seen this patient twice already this month? Irritated because you can’t work out who all the other freelance GPs are who’ve already seen this patient? Demoralised for not having the fundamental means for recording auditable medical notes? Struck off for never having officially been enabled to record a consultati…OK, you get the idea.
Secret passwords and usernames are essential to working as a GP – recording contemporaneous medical information in the patient’s notes is a vital part of clinical management; and a medico-legal requirement. And if your password isn’t secret, and call me paranoid, someone else could falsify records in your name. So how come freelance GPs are so rarely given their own? Come on chaps, stand your ground and insist on one! Some of the clinical systems are pretty easy to set up, whereas others aren’t. For example, the procedure for setting up passwords on Microtest can be quite tricky. So we’ve been working with them (and what nice people they are) to make the procedure easier.
@NASGP Huge risk area. I had my name signed to referral letter for a pt I'd never seen. V diff to ensure audit trail in such a setting...
— Dr Catherine Harkin (@buletproofcardi) March 13, 2015
Meanwhile, here is a download to place under the noses of any defaulting practices.
These allow clinicians to make a physical record of every consultation that needs referral, reducing the likelihood of a referral going missing.
NASGP's Standardised Practice Information Portal (Spip) allows any practice to present all 200+ items of shared information immediately in front of all its clinicians at the point of patient contact.
Although every GP knows tens of thousands of 'bits' of clinical information that he or she can formulate into a diagnosis and management plan within minutes of seeing a patient, when it comes to managing that patient's condition, they need to have access 200+ 'bits' of very localised non-clinical information about practice processes affecting safe patient management (e.g. managing test results, referrals, handover arrangements, prescribing procedures etc) and how the practice interacts with local resources.
Even for an established senior partner, practice processes, regulatory requirements and other local non-clinical information can change at a frightening pace, so having instant access to this information isn't just a luxury but a central requisite of modern patient management.
It's far safer, and more efficient, to spend two minutes updating information centrally in Spip than having a GP interrupt their surgery for 10 minutes to ask a staff member or another GP.
Now take into consideration the position of a locum GP, who can typically work in around 30 different GP practices every year, where in each of these practices, practically all these 200 'bits' of non-clinical information can be alien to them. By enabling all clinicians caring for your patients to have instant access to your Spip, you'll be empowering them to be better at what they do, and more efficient. No more time wasted having to interrupt the consultation to ask for simple but essential non-clinical information.
Locums may be most at risk of falling into pitfalls created by gaps in information about practice procedures but practice-based GPs and staff may also be prone to errors and misunderstandings. For instance, evidence from Medical Protection suggests that 57% of 107 practices undergoing a Clinical risk self assessment (CRSA) were found to have risky referral systems, often related to lack of understanding of referral protocols by practice staff and clinicians.
- Improve the quality of admissions and referrals by all clinicians who work in your practice, whether full-time, part-time or an ad-hoc locum basis, by making sure all this information is at their fingertips. Especially useful if you’re taking on a new partner, salaried GP or GP registrar.
- Increase efficiency by enabling any clinician or staff-member to access any piece of important information about patient management within 3 clicks of a mouse, whether they’re in surgery with a patient, at home or on a visit.
- Improve patient safety by publishing simple but important practice-specific procedures and safety-netting information for all clinicians and staff to relay to patients.
- Better value for money from ad-hoc staff and clinicians such as locum GPs and nurses; they can review your Spip before arrival, access it on the day, and they’ll be able to spend more of their time on direct patient care rather than having to bother busy members of staff.
- Satisfy the CQC that you are publishing essential information to all clinicians and staff who care for patients in your practice.
- Reduce errors by having this information in one central place that can be updated instantaneously.
Do your referral letters contain the necessary information in an accessible format that will allow for a smooth, timely referral experience for your patients?
This template consists of a 10 point scoring system of items that characterise a quality referral letter to allow you to grade the quality of your referral letters. It includes a framework to record a first round data collection and then a follow up second round data collection to review your progress. A great QIA to carry out on your own or as a GP learning group.
Did you refer the patient to the right place at the right time?
As a locum it can be especially challenging to get feedback on our referrals. Nonetheless, this is a valuable area of learning in how to use local resources efficiently, and most importantly, doing our bit in helping our patients have the smoothest, safest journey possible.
Focus on a particular type of referral or take a slice of consecutive referrals. This template gives tips on how to keep a log of patients of interest, the issues to consider when accessing medical records after you've left the practice and a framework for reflecting on whether the referral went as planned.
Referral letter outcome review for audit ideas for your referrals.
Writer and editor at MPS. MPS’s educational risk management workshops, ‘Mastering Professional Interactions’ and ‘Medical Records for GPs’ provide further information on the risks to patients and doctors when patient care passes between doctors, and on good record-keeping. They are free as a benefit of membership to MPS members too.