Specific template referrals labelled ‘tedious’ by frustrated GPs

Filip Vukasin

19/04/2023 5:17:47 PM

The trend is resulting in a growing number of rejections, forcing clinicians’ attention away from patients and onto ticking boxes.

Frustrated GP at computer.
Hospitals are increasingly rejecting GP referrals and requesting that they are instead completed on their own tailored templates.

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‘There is also the “you are using an outdated template, so your referral is rejected” letters,’ the WA-based GP said.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?’

Referrals-article.jpgGPs 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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Dr Bram Singh   20/04/2023 5:24:00 AM

Bureaucratic madness.....once again.
Thanks for speaking for all of us.
Ucantseeme.... But I'm so FUMING. 😡

Dr Adeel Ashraf Chaudhry   20/04/2023 7:45:13 AM

I agree, it is a tedious and clunky process. The question is, who do we talk to about making changes and improving the system? What is RACGP doing about it?

Dr Thanh-Thuan Nguyen   20/04/2023 8:13:12 AM

Excellent precise Article!!! for GPs to use as standard Macro/Copy&Paste LINK in GPs’ Referral Templates (but recipient hospitals, specialists, incl medicare itself will intentionally ignore to read) re extremly Time Wasting, Costly, Clinically Care Obstructing Red Tape Referral Criteria.

I routine give patients Open Referrals eg “To Any General Surgeons/Psychiatrists/Gyn etc” with Link below:
(as per medicare, specific Specialist names are optional, not required anymore:
but Specialists Admin still do old routine of req patient to come back to GP for “Named Referral”, instead themselves Manually Overwriting Letterhead!

The medicare Link above clearly states:
“ Referrals don’t need to be made out to a certain specialist or consultant physician.”

Evolving Earthquake of GP Frustration and Deepening HealthCare Crisis! on all fronts .

Dr Philip Ian Dawson   20/04/2023 9:11:37 AM

The solution is simple, the public health system needs to (1) send Templates to GPd as an RTF or Word Doc which can be easily incorporated into clinical software
(20 do what provate providers do. while many do have templates, thy are (mostly) happy to accept a referral on our letterhead provided it contains all the required information.

while you are onto the beaurocratic mess ( deliberate, its a make work scheme for beaurocrats and a choke point for referrals!) wy so car plans last exactly 12 months and unlike other expiring referrals the GP cannot do a new one BEFORE the old one has expired. meanwhile to Allied Health form that goes with it doesnt match, it only lasts for the calendar year! Who devised this mess? Do they expect GPs to hold them in high regard for their skills because of this?

Dr Pradeep Harshan Jayasuriya   20/04/2023 12:39:06 PM

Dr Ward is right to be angry and her comments are sadly an accurate reflection of what is happening. It is a disgrace that our specialist colleagues in WA have allowed this to happen.

Dr Nichola Lea O'Reilly   20/04/2023 4:51:07 PM

I disagree. I will now only refer patients to the Townsville University Hospital using their SmartReferral system. May take a little longer but all the info is there and the referral is processed quickly. Immediate confirmation of receipt of referral helps. There is a liaison officer to email if any problems. Well done Townsville.

Dr Kirsta Craig   20/04/2023 7:15:54 PM

I think this is a back handed way to cut their waiting lists in 1/2. Keep adding requirements until you reject enough referrals. No other reason I can see.

Dr Ingrid Ann Francis   20/04/2023 9:16:50 PM

Not accepting referrals until a long list of required investigations are done risks referrals not getting sent if patients don't get "required" tests in a timely manner and this may have serious consequences. I had a near miss recently due to this scenario.

Ross White   22/04/2023 7:50:18 AM

Using HealthLink templates helps with time but it annoyed me that in one instance the hospital clinic rejected the referral as outside of their criteria to be seen at the tertiary hospital and should go to a secondary hospital clinic that doesn’t take Healthlink, so a referral letter had to be done. What was worse, the tertiary hospital clinic did inform me of their rejection- only when the patient phoned to ask about when they would be seen, the tertiary hospital clinic informed them of the rejection and to go back to the GP for a referral to the secondary hospital clinic. The tertiary hospital made no attempt to inform me of the rejection.

Dr Afshin Tayeba   22/04/2023 11:54:18 AM

It’s certainly a true backwards in the broken health system. I believe the college should step up and make a discussion about this referral issue.

Dr Christos Papachristos   23/04/2023 10:35:38 AM

What is the RACGP doing?
As usual, nothing.