Referral risks

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.

[Tweet "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.

Other steps

  • 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. ●

Rachel Birch

This article was first published in the October 2015 edition of the NASGP's The Sessional GP magazine.

Charlotte Hudson

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.

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1 Response

  1. Michael A Kashden
    My surgery informed me that my referral for urgent cataract surgery had been sent to BARNDOC. (Barnet National Health) My surgery confirmed that they had phoned many times and that Barndoc should be blamed for not having arranged the surgery. Eventually the surgery was arranged 26 weeks after my eye test (Way outside the National Health constitution of 18 weeks maximum) and so many operations are cancelled that I could not be sure that the surgery would have taken place even then. I was going blind in one eye and could not drive or even read and therefore decided to have private treatment. My doctor blamed Barndoc for not actioning my referral. Perchance, I met another patient from our surgery who told me a similar story. The surgery insisted that they had sent her referral to The Royal Free Hospital yet the hospital knew nothing about it. It now seems that the error appears to be with my surgery and whilst our doctors are exceptional, the administration fails. This has obviously cost me a substantial amount of money. Should I take this matter to the ombudsman to attempt to be reimbursed?

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