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Rejected referrals ‘compromising patient care’


Jolyon Attwooll


22/08/2022 5:29:34 PM

Cost-shifting and the used of outdated technology have been identified as the main causes for a trend GPs believe is putting patient safety at risk.

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GPs believe issues with referrals to specialists are affecting patient care.

‘I’m really frustrated from a clinical perspective that this is happening.’
 
So says Melbourne GP Dr Mariam Tokhi, who has raised the vexed issue of rejected referrals again.
 
She went public with her frustrations last week after referring a patient to see a specialist at Western Health.
 
The referral was subsequently rejected, with the health provider asking for it be reissued. Dr Tokhi was informed that the referral was ‘non-compliant with Western Health named referral requirements’.
 
‘In order to enable our patients the choice to be treated as a public or private patient, we request that this referral be addressed to the Head of Service,’ it stated.
 
For Dr Tokhi, the example is commonplace, and she believes it shows a systemic failing that is compromising patient care.
 
‘It takes up time,’ she told newsGP.
 
‘It’s five or 10 or 15 minutes for each patient but if you get multiple rejections every week like I do, it adds up.’
 
A GP at Utopia Refugee and Asylum Seeker Health Clinic in Hoppers Crossing, Dr Tokhi says her patients are at risk of getting lost in the system if it does not function as it should.
 
‘I work with a particularly vulnerable group of patients, many of whom don’t speak English,’ she said.
 
‘They are really dependent on systems to work well, often for quite serious medical issues, so that they don’t get lost to follow up.’
 
She also highlights the outdated technology in use, with the referral managed by fax machine.
 
‘It feels really unsafe, it feels like it’s compromising patient care,’ Dr Tokhi said. ‘Faxes go missing all the time. It’s just another opportunity for something to go wrong.’


Dr Joe Garra, another Melbourne-based GP, advised Dr Tokhi to send a templated letter that points out there is no obligation for GPs to provide named referrals for outpatient services under the National Health Reform Agreement (NHRA).
 
He says that he has never had an issue with hospitals insisting on named referrals since using the template.
 
However, Dr Garra does report encountering various other frustrations and barriers when referring patients to hospitals, including requests for blood and urine tests that he believes are often of limited use by the time the patients are seen.
 
‘It’s almost as if the public hospitals don’t want to see our patients,’ he told newsGP.
 
‘They always seem to find a little reason why [not]. It’s frustrating for us as GPs that hospitals unilaterally set these rules.
 
‘I understand why hospitals are doing it. But they are funded to run outpatient departments.
 
‘Their issue should be with the state government not funding them properly. If they are not funded enough by the state that’s the problem, don’t make that the GP’s problem.’
 
One Medicare expert, Dr Margaret Faux, has previously pointed out that without a named referral hospital outpatient services cannot be funded by MBS rebates.
 
GPs have been encouraged to report any concerns if they believe hospitals are wrongly mandating named referrals for access to outpatient services.
 
Dr Tokhi says she will consider Dr Garra’s templated approach but, in this instance, simply sent back a named referral.
 
‘I re-referred with the name of the specialist because I just want my patients to be seen,’ she said.
 
Dr Tokhi emphasises that her frustration is directed at shortcomings across the whole health system.
 
‘It’s not a particular institution I’m trying to call out,’ she said. ‘All institutions are doing this, every single hospital system I’ve ever interacted with.
 
‘It speaks to an underlying issue around cost-shifting, and it has huge impacts for patient safety and care.’
 
A spokesperson for Western Health said that the requirement for named referrals is to allow for MBS billing.
 
‘Some services at Western Health are registered as MBS-funded clinics,’ they said in a statement provided in response to a newsGP inquiry.  
 
‘When referring patients to an MBS-funded clinic, GPs must address the referral to the relevant Head of Unit in order to meet MBS funding eligibility requirements.’
 
They also said more information about the clinics and heads of unit is available on the Western Health website.
 
The college, meanwhile, advises that it is acceptable for a specialist to ask for a named referral if a patient has decided to be treated privately.
 
‘However, the choice to be public or private is for the patient, patient’s carer or other authorised party to make, with informed financial consent,’ RACGP guidance states.
 
‘GPs are not required to help patients decide, but many do, and it can be helpful for patients to understand the implications above before booking an appointment.’
 
The college also advises that if it has been discussed, the patient’s preference for public or private care should be included in the referral.
 
‘Patients can make a decision with you, or when they book the appointment, or when they attend the outpatient clinic,’ the advice states.
 
‘If the patient is unsure, it may be best to provide a named referral – this will ensure the patient does not have to seek an additional referral before being seen, if they subsequently decide to be private.’
 
More details on advice for GPs on named referrals are available on the RACGP website.
 
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Dr Michael Charles Rice   22/08/2022 9:33:08 PM

"referral pathways must not be controlled so as to deny access to free public hospital services" and "referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services" NHRA G17 b,c

1. Let's stop calling them "named referrals" and label them accurately as "private referrals".

2. Hospitals seem to SAY ‘In order to enable our patients the choice to be treated as a public or private patient...' when I think what they MEAN is 'In order to grant the State the choice of treating the patient according to our priorities not theirs...'

3. I'd feel a whole lot better if these hospitals would simply provide a patient-centred explanation of how the choice of being "treated as a private patient" under National Health Reform Agreement G19 b differs from the default public care

https://federalfinancialrelations.gov.au/sites/federalfinancialrelations.gov.au/files/2021-07/NHRA_2020-25_Addendum_consolidated.pdf


Dr Arshad Hussain Merchant   23/08/2022 5:48:51 AM

This is just another excuse for patient been referred to private clinic. Even with a named referral, patients are not seen by the named specialist but some junior trainee doctor as the named specialist is out in his private room! The only solution is no specialist is allowed to do private practice during 8am to 6pm, this will reduce patient waiting time and improve public clinic care! I cannot understand how much greed hospital have! I came out referral requests for 2 x name specialists for a pacemaker check clinic when it is run by technician…. MBS compliance rules should be applied to all these specialist claims! If a specialist is paid for his services and hospitals are funded to hire that person, there should not be any further MBS claims


Dr Vijai Gupta   23/08/2022 6:38:41 AM

This just creates delay for patient to get the proper help !


Dr Alan Robert McLean   23/08/2022 7:26:00 AM

well done for pushing back against the ever increasing burden of medical bureaucracy !


Dr Lagan Grover   23/08/2022 8:56:46 AM

I have recently encountered a referral being knocked back by a public hospital due to long wait list. The patient certainly falling into the catchment. When this was addressed I was told better to refer privately or elsewhere!
Disappointing and frustrating to say the least.


Dr Henry Arthur Berenson   23/08/2022 10:32:08 AM

We are dealing with a filtration system, not triage. Filters are designed to reject unwanted material. Triage determines where the patient should be directed. The fix is to empower the patient. Give them the referral and then they negotiate with the department. Less medicolegal risk for the referrer.


Dr Bradley Arthur Olsen   23/08/2022 4:20:20 PM

You could take the approach I have in Bundaberg general practice.If an appropriate referral that follows all queensland health clinical guidelines is REJECTED. I make a complaint to OHO/AHPRA about the director of the dept. Advise the directors first , then if it happens- ACT- i have referred 2 consultants ----so far . I am tired of coping abuse from patients and referrals to the board due to referral rejection for no valid reason- I no longer make named referrals to certain depts at Bundaberg due to their non co operative nature,if they reject because of this---guess what - AHPRA referral


Dr Olga Elizabeth Randa Ward   23/08/2022 5:52:47 PM

Thanks for saying this as publicly as possible! Given that we know our patient isn't likely to be seen by the named public consultant, could the feds please just give in and chuck some money at the outpatient departments specifically so we aren't always in this named referral bind? ( what if I choose one of the 6 in the template and the patient is seen by another? Where does that leave the hospital for liability? What if the patient insists on being seen and managed by the consultant- that would be their right under a named referral?

I might add that there are referral criteria for places like urology- they need urine cytology and an MSU result- fair enough. Before they accept the referral. But they also want full urodynamic studies done for an incontinent patient BEFORE acceptance. Where does the patient get those studies in the public system? Well ONLY at the hospital that rejected the referral for the assessment...
So much rubbish that the GP is supposed to sort out


Dr Greg Saville   26/08/2022 11:46:15 AM

I use "nudges" when I have my referrals rejected.I know there was some shrill indignation when GP's received "nudge" letters a few months ago. But, nudges can be used by GP's too with good effect. I had three of my referrals to a private psychiatric service rejected recently (the psychiatrists being "too busy" or their "books were full"). The next referral letter to this service I added a handwritten annotation stating that "my last three referrals had been rejected". A simple statement of fact. This last referral was accepted.


Dr Michael Charles Rice   28/08/2022 4:06:47 PM

"referral pathways must not be controlled so as to deny access to free public hospital services" and "referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services" NHRA G17 b,c

1. Let's stop calling them "named referrals" and label them accurately as "private referrals".

2. Hospitals seem to SAY ‘In order to enable our patients the choice to be treated as a public or private patient...' when I think what they MEAN is 'In order to grant the State the choice of treating the patient according to our priorities not theirs...'

3. I'd feel a whole lot better if these hospitals would simply provide a patient-centred explanation of how the choice of being "treated as a private patient" under National Health Reform Agreement G19 b differs from the default public care

https://federalfinancialrelations.gov.au/sites/federalfinancialrelations.gov.au/files/2021-07/NHRA_2020-25_Addendum_consolidated.pdf