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June 26, 2016

Referrals to past experience

Dr Ruairi Hanley

Dr Ruairi Hanley has reservations over the new national referral template, as he fears hospitals may use it as an excuse to delay outpatient appointments.

It was with some interest that I read the recent article by Dr Brian Meade and Dr John MacCarthy on the subject of the newly-launched national referral template (Irish Medical Times, March 2, 2012, http://bit.ly/zzRiWO).  The authors begin by explaining that GPs in the UK were wasting 2.4 million appointments annually in form-filling and needless bureaucracy. I doubt that statistic will come as a surprise to anyone working in general practice in Ireland, where the situation is equally dismal.

Having identified a serious problem, the National GPIT Group have come up with a novel solution — create yet another form! I admit my instinctive reaction to this is one of hostility. Indeed, the phrase ‘pouring petrol on a fire’ springs to mind.

However, to be fair to my colleagues, their logic is that this new template will manage to supersede the enormous number of existing documents that doctors are obliged to use. Thus, it might be described as ‘the form to end all forms’.

My first observation would be that, in order for this approach to work, we would have to ensure that every HSE administrator in every hospital in the State would simultaneously agree to drop their unique referral documents in favour of the new template. As this has obviously not yet happened, how can we assume that it will?

Best of intentions
I appreciate that those GPs who took part in this process did so with the best of intentions and genuinely believed that the end product of their labours would improve our health system. Unfortunately, I am a long believer in the law of unintended consequences, of which I fear this new document may become a shining example.

My core reservation is simple. I believe that the creation of this template shifts the burden of responsibility from the hospital back to the GP and creates an additional potential barrier to the timely review of patients. Furthermore, I fear it may ultimately provide an excuse for HSE administrators to plausibly deny patients much-needed appointments.

Tallaght scandal
I recognise this is a controversial opinion and will probably anger many of those who support the use of the new form. In response, I would cite the recent scandal in Tallaght Hospital, where an inquiry revealed that over 30,000 GP letters were either unopened or unprocessed.

Essentially, I believe what happened here is that hospital administration failed to do their job and patients were potentially put at risk. Amazingly, rather than sanction those responsible for this fiasco, we are told that what is needed is a standard template of GP referral. I really have to gasp in awe at this subtle shifting of blame from those who failed to open the letters to those who actually wrote them in good faith.

Even if we leave aside my cynicism surrounding this episode, what possible evidence do we have that the same HSE administrators who could not open letters will somehow process a new referral form in a more timely fashion? The short answer is none whatsoever.

‘Responsibility free’
However, in my opinion, what a new, mandatory, template may allow these people to do is reject documents that are not completed to their satisfaction. This hands them a marvellous ‘responsibility-free’ method of shortening waiting lists and then blaming GPs.

It works as follows. GP refers sick person to Outpatient Department. Pen-pusher finds a missing box that was not ticked. The patient does not receive appointment and the finger is pointed at the GP for not filling in the form correctly.

If the people running our health service are capable of removing access to basic healthcare from thousands of vulnerable people, solely on the basis of bureaucratic technicality, why do we think they could not employ the same tactics with regard to waiting lists?

I can already hear some readers accusing me of paranoia. In response, I would ask them how many patients in this country saw their applications for medical cards rejected by the HSE, because they were completed incorrectly? How many others had their documents ‘lost’ or endured lengthy delays in processing?

If the people running our health service are capable of removing access to basic healthcare from thousands of vulnerable people, solely on the basis of bureaucratic technicality, why do we think they could not employ the same tactics with regard to waiting lists?

Another potential problem arises when those who genuinely support new innovations begin to believe that others should be required to think just like them. It is only a few short steps from ‘strongly recommending’ that the new referral form be used, to compelling every GP in the State to adopt it. I sincerely hope that those who are behind this document will not choose to go down this route.

I have never accepted that compulsion is a good way to encourage people to support any initiative. For example, allowing Christian Brothers to beat mandatory Irish into the heads of millions of young boys has not led to widespread love of our native language.

If this form is as good as its creators believe it to be, then most GPs, including myself, will choose to adopt it routinely. However, if the HSE sees it as a method to play games with appointments, then compulsory introduction of the document will only make matters worse.

In summary, although I have enormous respect for those behind this initiative, until I see genuine reciprocal goodwill from HSE administration, I will not be using the new template.


Hello, baby girl
I wish to conclude this week with a happy announcement. On February 27, my dear wife gave birth to our first child in Cavan General Hospital, a little girl named Roisin.

Poor, brave Mrs Hanley had a tough time, but was cared for brilliantly by the obstetricians, anaesthetists and midwives.

In particular, we would like to put on the record our eternal gratitude to Dr Salah Aziz, Dr Salan, Dr Syed, and their teams. We also wish to thank all the staff of the labour and postnatal ward who were eternally patient and kind.

As for little Roisin, her arrival was the reason for my absence from this year’s Cheltenham. But at the risk of sounding soppy, she is worth missing a hundred festivals!