Medico-legal: How GPs can deal with referral delays caused by COVID-19

The MDU's Dr Kathryn Leask outlines steps GPs can take to try and avoid patients coming to harm as a result of delayed referrals and provides advice on dealing with patient complaints on this issue.

Referral delays (Photo: Photofusion/Getty Images)
Referral delays (Photo: Photofusion/Getty Images)

The COVID-19 pandemic has brought many challenges, some of which have been overcome by the dedication and creativity of those working in the healthcare sector. However one continuing concern for GPs has been the delay in patients being seen for non-COVID-19 issues once a referral has been made to a specialist.

In the midst of the pandemic, the majority of routine hospital work was put on hold and with a backlog of patients on waiting lists, patients still aren’t being seen as quickly as they would normally have been.

A GPonline poll of 415 GPs in May this year found that 77% were concerned delays to operations and treatments for non-COVID-19 issues would result in patients coming to harm. Meanwhile, 30% of GPs said an urgent referral had been rejected at the time the survey was undertaken.

This will potentially have serious implications for patient care in the longer term and for GPs, it could lead to complaints and criticism.

Managing patient expectations

However, there are some steps GPs can take to try to avoid patients coming to harm while putting themselves in the best position to address the potential medico-legal ramifications.

In their guidance on Delegation and referral the GMC says that you are not accountable for the actions or omissions of colleagues to whom you make referrals. However, you are accountable for your decisions to transfer care and the steps you have taken to make sure that patient safety is not compromised.

If you are aware that there are delays for a particular service and your patient is likely to be affected by this, you should make this clear to them and manage their expectations from the outset.

Practical tips for GPs

Other actions to take include:

  • Ensure the patient understands whether the referral is urgent or routine and the timescale you expect for an appointment. Ask them to get in touch if they do not hear anything by that time.
  • Provide safety netting advice to the patient so that they know what to do if their symptoms deteriorate before their referral is actioned. 
  • Discuss alternatives with the patient, for example, their thoughts on a private referral.
  • Discuss with the patient any sensitive information that you plan to include and explain why it is clinically relevant to do so. If the patient refuses to consent to you disclosing information explain the risks associated with this.
  • Ensure you make the urgency of the referral clear. For urgent referrals, highlight the relevant clinical detail to avoid this being relabelled as a routine referral if triage is carried out.
  • Detail all relevant clinical information in your referral including the patient’s history, medication, allergies, examination findings and details of any investigations.
  • Ideally type referral letters if they are not being sent electronically, but if handwritten, ensure writing is legible.
  • Sign and date the letter, include your contact details and retain a copy in the patient’s medical records.
  • Report any deterioration or new symptoms to the person or department you have referred the patient to. Inform them about any updated investigation results.
  • Consider if further care can be offered in the interim, for example, by discussing the patient’s condition with the health professional you have referred the patient to.
  • Consider putting a practice policy in place so that patients who have been referred, where you know there is a long waiting time, are reviewed and the progress of the referral monitored.
  • Ensure continuity of care if you are no longer available or are due to leave the practice.  Handover to another clinician making them aware of the referral and the patient’s condition.
  • Discuss any specific concerns with your local medical committee while protecting patient confidentiality. If you are experiencing difficulties, it is likely that other practices in the area are as well.
  • Investigate any complaints in the usual way, offering an apology where appropriate and providing the patient with an explanation and informing them of any learning points that have been identified. Also see the MDU’s full guidance on dealing with complaints.
  • You have a responsibility to raise concerns if you think that patient safety is or may be seriously compromised.
  • Get advice from your medical defence organisation if you face criticism as a result of a delayed referral or if you are concerned about the impact on safe patient care.  

Case example

The following case is fictitious but based on the types of cases that could occur.

A 70-year-old man consulted his GP during the height of the COVID-19 pandemic remotely by video. The patient had been suffering from urinary symptoms for some time, including frequency and hesitancy. A PSA carried out about three months earlier was normal.

The patient was otherwise well, with no weight loss or pain, but had an episode of frank haematuria. The GP noted he suffered from urinary tract infections in the past and prescribed antibiotics. However, due to this new symptom she also referred the patient urgently to secondary care under the two-week-wait rule.

After three weeks the patient still hadn’t received an appointment and had a further episode of haematuria. The GP rang the urology department to try to expedite the appointment. Many staff at the hospital had been redeployed to assist with the pandemic and clinics had been cancelled. The trust was also experiencing staff shortages due to sickness.

The GP apologised to the patient for the delay and provided safety netting advice. The patient was offered the option of a private referral, which he declined.

By the time the patient was seen, eight weeks had passed and he had now begun to lose weight and experience back pain. He was diagnosed with a renal cell carcinoma and later made a complaint to the practice about the delayed referral.

With the help of the MDU and her comprehensive notes, the GP explained what actions she had taken to speed up the patient being seen as soon as she became aware of the delay. The GP apologised again, explaining the difficulties caused by the pandemic. The patient was satisfied with the response and accepted that the GP had done all she could in the circumstances.

  • Dr Kathryn Leask is an MDU medico-legal adviser

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