Referral Management: How armed forces GPs refer patients

Can England's commissioners learn from work in Germany? By Dr Jeff Macleod and Dr Charles Alessi

At Hohne Garrison, the Desert Rats' base, clinicians have developed a triange pathway for referring soldiers and members of their families (Photograph: Getty)
At Hohne Garrison, the Desert Rats' base, clinicians have developed a triange pathway for referring soldiers and members of their families (Photograph: Getty)

GPs in British Forces Germany Health Service (BFGHS) are in a unique situation as they aspire to UK-accepted best practice, as well as referring patients into a contracted German secondary care health service - a system of funding and operation that is fundamentally different from England's.

The fact that patients move across two differing health systems necessitates putting in place processes to mitigate any risks to them.

Dr Jeff McLeod is responsible for the healthcare of the Hohne Garrison which includes the Desert Rats. This team is responsible for both the soldiers and their families spread over north Germany. The referral management solutions we have come up with are a shared achievement and could not have happened without the full support and encouragement of everyone involved in patient care.

Dr Charles Alessi who is the BFGHS's director of medicine and clinical governance, describes this initiative as an example of true innovation.

'The concept of a complex case meeting clearly has antecedents in the cancer multidisciplinary team meetings and in many respects it fulfils the same aims, garnering expertise from all clinicians to manage the patients in the best way possible.'

Dr Mcleod says: 'In an attempt to achieve this at Hohne Medical Centre we have developed a new triage pathway for potential referrals.

'We use existing resources in a different way, whilst maintaining the basics of our old referral system, to optimise management of our more complex cases.'

The process has five steps

Step 1:
A clinician believes the care the patient requires may necessitate consultant referral. The clinician manages the case by informing the patient their case is more complex than can normally be managed in primary care, and that options for ongoing management mean referral to the practice's weekly complex case meeting (CCM).

Step 2:
The patient is given an electronically generated CCM booking form that they are asked to give to the relevant practice clerk who then manages the administrative aspects of the potential referral.

With our transient population and separate clinical and personnel IT systems, contact details need constant checking. It is important we have the most up to date details for any patient who may require referral. A standard referral form to the specialist is generated.

Step 3:
The clerk updates the contact numbers, advises the patient of the CCM date, then logs the referral and collates the referral forms. These are then passed on to the medical officer in charge immediately prior to the next weekly CCM, involving all practice GPs.

Step 4:
Clinicians discuss cases at the CCM, agree on the most appropriate next step, document this on the referral form and the cases returned to the clerk. The next step may be referral to a German consultant in a German hospital or referral of the patient directly to a UK consultant. Other options include referral to another member of the primary care team with a special interest.

Step 5:
If the CCM conclusion concurs with that suggested by the GP to the patient, the clerk will contact the patient and advise them of the CCM recommendations and then, with the patient's agreement, the relevant appointment is made. If the plan has changed, the GP may wish to contact the patient as well to ensure they are involved in this process and fully aware of developments. The clerk will then contact them with the appointment.

Cases that cannot wait for the CCM and are deemed too urgent to be managed in this way are referred immediately and, when possible, discussed with the medical officer in charge as soon as possible.

Musculoskeletal complaints are the most common cause for referral in British Forces Germany, at 25 per cent of all outpatient activity.

Policy determines that all these patients have an initial consultation that always involves a physiotherapist. The benefit of this pre-treatment is that a specialist physiotherapy assessment can be made of the appropriateness of a secondary care referral. Planning for posttreatment physiotherapy can start immediately, so speeding recovery and lessening the amount of time a soldier is not available for duty.

Referral management has received a mixed press. Some initiatives in England have been successful while others have either not been supported or simply been deemed unsustainable.

The importance of local ownership rather than imposition of process is what could make the difference. The Hohne referral system is owned by the clinicians involved and retaining that local ownership makes sustainability more likely. It has full patient involvement. Each patient is kept informed of where there referral is at all times. Finally it involves a new role for the practice clerk, who is now far more involved in the process of referral and also takesresponsibility for tracking referrals to ensure no treatments or referrals are overlooked.

We believe this process has aspects which could be borrowed and implemented in England.

Following a single practice process for referral is part of what the new NHS reforms are trying to achieve.

Clearly issues around patient choice would need to be incorporated, and the patient needs to be fully supportive.

However referral management encourages clinicians to work in a more corporate fashion and encourages the sharing of good practice again is part of what the NHS reforms are trying to encourage.

  • The most appropriate management of a patient is ensured.
  • Process contributes to GP's CPD.
  • Quality of written referrals is enhanced as the referrer knows their referral will be peer-reviewed.
  • Referrals cut by ensuring only most appropriate are forwarded.
  • Changes from previous referral process are minimal, making the system easier to implement.
  • Dr Jeff Macleod is medical officer in charge of the Hohne Garrison and Dr Charles Alessi is a Kingston, Surrey GP and director of medicine and clinical governance for the British Forces Germany Health Service

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