Specific template referrals labelled ‘tedious’ by frustrated GPs

Services Australia has an online page outlining the legal obligations when referring and requesting services under Medicare.
 
Some are well known, such as the need for relevant clinical information, the date of the referral and the signature of the referring practitioner.
 
Others are less known, such as ‘the referral starts from the date the specialist first meets the patient, not the date issued’.
 
The need for specific templates is not mentioned – anywhere.
 
However, GPs report that hospitals are increasingly rejecting their referrals and requesting that they are instead completed on their own tailored templates.
 
For Dr Christopher Mitchell, a GP in Ballina East, New South Wales, the imposition is irritating – and takes him away from patient care.
 
‘[It’s] usually accompanied by a file as a PDF that I can’t use in my clinical software. Sometimes it directs to a website. That’s even worse,’ he said.
 
‘Even when there is a single template approved, [some] clinics create a new front sheet requirement that must be filled in, and again it’s sent to us as a PDF.
 
‘We already have HealthLink templates established that can autofill, so the solution is pretty simple. While the implementation does generate some costs, the current process costs too.
 
‘It costs us time.’
 
On the other side of the country, Dr Olga Ward is becoming equally frustrated by what she told newsGP is a ‘tedious’ trend.
 
‘There is also the “you are using an outdated template, so your referral is rejected” letters,’ the WA-based GP said.
 
‘They don’t send back a link to a new template – they expect the doctor to Google it or something. I just want to write a proper clinical handover to be read by a competent clinician.
 
‘And I don’t want to have to search guidelines to find out what each hospital in the state wants in its referral, which I’d have to find on the hospital’s site by Googling.’
 
The use of the Central Referral Service (CRS) in Western Australia only complicates the matter.
 
‘We have no actual idea which hospital the patient will end up at and it’s more than a little frustrating to have a referral sent and then rejected … because they have some blasted guideline for the referral to their department that I’m unaware of,’ Dr Ward said.
 
‘I do not have time for this, I’m a clinician, not a bloody secretary!’
 
Even with integrated templates, Dr Ward says the system can be clunky, full of boxes to tick and areas for attachments that do not always transfer from the software.
 
‘I hate it. I am not a box ticker,’ she said.
 
‘I also am very pressed for time and am not at all happy at having to expend energy on clunking through a template that treats me like a primary kid and doesn’t even auto-populate with the patient’s demographics, nor with their history.
 
‘I’m starting to want the Danish system where all the health software across all systems has to – by law – be compatible, communicate and contain all the information readily available.
 
‘Imagine how many tests would not have to be endlessly repeated if you could see it all there at once and look up what has gone before.’
 
As it stands, she says some hospitals have such long templates that it seems every single consultant on staff is listed.
 
‘You are supposed to tick which consultant you would like your patient to see,’ she said.
 
‘This makes it a “named referral” for the purposes of state hospitals extracting money out of Medicare. [But then] the template also specifically states that your patient might not be seen by the requested consultant.
 
‘So what is the point of wasting three pages on lists of consultants?’

GPs say that the lack of optimisation in the referral system is creating unnecessary red tape.

It is not the first time GPs have flagged issues with Australia’s referrals process, and they say the problems extend well beyond just the request for specific templates.
 
There is anger about the use of fax machines, named referrals, surgery being rejected for ‘arbitrary’ reasons and generally delayed communication between hospitals and GPs.
 
And aside from adding red tape to a general practice sector already under enormous strain, GPs say it has a large impact on patients as well.
 
‘The patient has to be there with me for the time it takes to sort it out,’ Dr Ward said.
 
‘They are paying for that time. They do not like it when it takes 20 minutes to sort what they see as “just a referral” and they do have to pay for a long appointment for that.
 
‘They are also horrified when their referral is rejected and take it personally.’
 
According to Dr Mitchell, the main requests are from outpatient departments, with private specialists and many allied health services also starting to adopt similar policies.
 
For Dr Ward, gastroenterology departments are frequent offenders.  
 
‘But [then] they accepted an urgent proper letter with some results and managed to act on it within a couple of days without all the tick boxes, so I know they can do it,’ she said.
 
Another scenario she describes sounds almost ‘Kafkaesque’ in nature.
 
‘I’m a bit dark on departments like urology rejecting a referral for very serious continence issues in a younger patient because I hadn’t included copies of urodynamic studies,’ Dr Ward said.
 
‘The only place these studies were available via the public system was via the department that rejected the referral. They got a very strongly worded letter back and have now added the patient to a two-year wait list.’
 
All of this leads to more work for GPs, delayed treatment for patients and ultimately resentment.
 
And while Drs Ward and Mitchell understand the need for detailed and clinically relevant referrals, they say the current system is not optimised.
 
‘Clinicians may require some specific details, [but] the process is often handled at an administration level by staff with little clinical understanding,’ Dr Mitchell said.
 
‘I’ve started writing back to the department heads and explaining my issues by asking them how they would feel if they had to reply to me on my individual template or had to manage a different template for every response to a referral.’
 
Dr Ward is also a rural generalist and says she gets some ‘totally appalling referral letters from colleagues’.
 
‘So, I do understand why they have a template,’ she said.
 
‘I don’t think there are easy answers, but I do wish that the tertiary system didn’t treat experienced clinicians as if we were the lowest common denominator.
 
‘I wonder if there are specialist surgeons or ophthalmologists or paediatricians who refer into the system having to fill in this sort of template with tick lists? I bet they don’t have to type all the rubbish details in themselves.’
 
But whether or not there is rationale behind the requests, the issue of template-specific referrals appears to be just another example of how the referral process is not optimised, leading to anger, swollen bureaucracy and frustration for patients, GPs and hospitals.
 
‘Do I sound like a very angry GP?’ Dr Ward asks.
 
Perhaps she speaks for everyone.
 
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bureaucracy hospitals red tape referral template