Systemic failures resulting in potentially millions of ‘lost' GP referrals to hospitals for specialist care

Posted: 20/02/2023

A recent analysis by Healthwatch England, a patient watchdog, suggests that millions of patient referrals from GPs to hospitals for specialist medical care are either rejected, cancelled or lost by the hospital or, in other cases, not sent by the GP at all.

The survey of almost 2,000 people who were referred by GPs to specialists discovered that one in five had fallen into a ‘black hole’ and had not received the specialist medical advice or treatment that the referral was intended to arrange. Scaled up to national level, Healthwatch England estimates that nearly 2.5 million people may have been affected between November 2021 and October 2022.

What are GP referrals and why are they sent?

GP referral letters are incredibly important. Whether a referral letter is sent depends upon what the GP feels is clinically necessary.

If a GP feels that a referral is required, then it will usually be because the GP wants a specialist’s help in deciding on the best way to treat a patient’s condition. This might involve referring the patient for tests or investigations that cannot be carried out in a GP surgery. For example, a GP may refer a patient for scans or tests to investigate a patient’s condition or health issue, for physiotherapy, or for minor surgery.

Generally, patients cannot self-refer to a specialist, unless when accessing A&E, and a specialist doctor will usually only see a patient if they have received a letter of referral from the GP. The letter will give essential background information, such as medical history, and it will also contain details that the specialist needs to consider particularly, for example, any abnormal examination findings. There are typically two types of referral letters that GPs can send: routine referral letters, and urgent referral letters.

Routine referral
If a doctor has decided to refer a patient for further/specialist care at a hospital, the doctor will complete a referral letter that will not be marked with any specific urgency. The referral letter should be completed and sent by the GP within five days of the GP appointment, and the referral will then be triaged by the receiving hospital to determine when the patient needs to be seen in hospital. An appointment letter should then be sent to the patient. Sometimes in England the patient will be given the opportunity to choose the hospital in which to be seen.

The NHS constitution states that, if a GP has referred a patient for a condition that is not urgent, the patient should be seen by a consultant within 18 weeks of the date of referral.  

Urgent referral
The other type of referral that a GP may send is known as an ‘urgent’ referral, or a ‘two-week’ referral. A referral of this type is issued when the GP has concerns that the patient has a condition or illness that needs urgent investigations, such as when cancer is suspected.

If a patient’s condition or illness requires an urgent referral, then the GP should send the referral letter on the same day as the appointment, or at least the next working day, and mark the letter as urgent. Once the referral has been received by the specialist hospital department, the patient should be contacted and offered an appointment within two weeks of the date of the referral.

Some illnesses and conditions are known to be associated with far more favourable outcomes if the illness is diagnosed and treated early. It is therefore very important that urgent referral letters are sent correctly when they are required.

Consequences of failures in the GP referral system

Healthwatch England said that vast numbers of referrals from GPs to other specialists are rejected, cancelled or lost by hospitals. Separate NHS data has shown that the proportion of referrals being rejected by hospital teams is now 43% higher than it was before the pandemic. In other cases, promised letters were not sent by GP teams, the referrals were sent to the wrong place, or patients simply reported hearing nothing more. It is unclear from the survey whether the referrals that were not actioned were routine or urgent referrals.

Louise Ansari, the national director of Healthwatch England, said: “Falling into this ‘referrals black hole’ is not just frustrating for patients, but ultimately means people end up going back to their GP or visiting crowded A&E departments to get the help they need. This adds more burden on already stretched services, making things even harder for the doctors and nurses trying to provide care.”

If the figures suggested in Healthwatch England’s analysis are correct, then the failures in the GP referral system are potentially far more serious and could be putting thousands of patients’ safety at risk.

Arran Macleod, a senior associate in the clinical negligence team, comments: “In our work we often see the consequences of a delay in diagnosis and treatment of illnesses. In cancer cases, for example, it is well known that the earlier the cancer is detected and treated, the more favourable the patient’s outcome is likely to be.

“However, if there are delays in the patient being seen by the specialist cancer teams at hospital because of either failures by the GP to send the referral, or mark the referral correctly, or failures by the hospital to record and log the referral and arrange an appointment for the patient, then it is conceivable that many possible cancers are not being picked up as early as they should be. This could have dramatic consequences for prospects of cure and survival.

“It is incredibly important that referral letters are, when clinically indicated, sent properly and marked with the appropriate urgency. Similarly, it is essential that referral letters (particularly urgent referrals) received into hospitals are taken seriously, and not rejected, misallocated or misplaced to ensure that patients receive timely input for worrying conditions.”

If you have any concerns over your care because of problems with a GP referral, then please do not hesitate to contact our specialist clinical negligence team for some preliminary advice.

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