Learning from analysis of general practitioner referrals to a general paediatric department

Abstract

AimsTo assess the value added to patient care by the input of the paediatrician following referral to a general paediatric outpatient department.MethodsThe authors received 200 general practitioner (GP) referral letters from the Primary Care Trust (PCT) over a 2-year period. The authors excluded letters to other hospitals and to non-medical specialties, such as paediatric surgery or ENT. A group of paediatricians reviewed both the referral letter and the return correspondence, and made a judgement on the relevance of the referral to hospital.Results70 pairs of letters were analysed. In 45, patient care was improved by referral to secondary care. In 25 it was felt the referral could have been avoided.The referrals which enhanced patient care: ▸ suspicion of serious underlying conditions▸ unclear diagnosis▸ treatment instituted by GP had not resolved the problem▸ further hospital investigation and management required However, there were instances in which improvements could be made: ▸ lack of information on the referral▸ incorrect diagnosis on the letter▸ referral being directed towards the wrong individual Other letters highlighted education and training issues: ▸ knowledge or confidence gap in the GPs' training▸ lack of confidence in treating children▸ lack of confidence by the GP in his own diagnosis This carries a cost implication—if 36% of the 1268 referrals to general paediatrics last year were potentially avoidable, this would represent a saving to the PCT of £110 000.ConclusionsThe authors advocate an integrated approach to healthcare for children in which GPs have easy and ready access to advice from paediatricians. There is a shortage of paediatric resources, partly due to different working patterns after the introduction of the European Working Time Directive. We must ensure the most appropriate use of scarce resources. With improved communication, the numbers of children requiring hospital review can be reduced. The authors feel that better links between primary and secondary care will improve patient satisfaction and GP education. In addition, parental confidence in GPs will increase as they become more confident in managing the child's condition. This will result in fewer avoidable referrals to secondary paediatrics.

Safety Incidents in the Primary Care Office Setting

“…However, ∼36% of referrals to pediatricians are thought to be avoidable with better family physician training. 39,41 Currently, as few as 40% of family physicians have pediatric training at a postgraduate level, causing many to support mandatory family physician pediatric training. 39 Our findings support such calls for mandatory pediatric training, as reported harm from incidents related to referral, treatment, diagnosis and assessment were frequently associated with errors of knowledge and patient assessment.…”

Improving child health services in the UK: insights from Europe and their implications for the NHS reforms

“…A recent study suggests that 36% of referrals to paediatricians are potentially avoidable 19 and this partly reflects lack of knowledge or confidence by general practitioners. Few trainee paediatricians spend any time in general practice, 20 however, and many feel poorly prepared for dealing with children who have minor illnesses but anxious parents and for the myriad behavioural problems and family and school difficulties often seen in hospital paediatric clinics.…”

Using an email advice line to connect care for children

“…Potentially avoidable paediatric hospital referrals indicate the need for further support for primary care health professionals,3 especially given that many have limited formal paediatric training 4…”