Guideline 31: Report on a Recommended Referral Document

Report on a Recommended Referral Document
Section 3: Implementation of the referral document

3.1 Referral letter template

The suggested template for referral communication has been produced in liaison with the Information and Statistics Division (ISD) of the Common Services Agency for the NHS in Scotland. National definitions and codes, where available, should be adopted and have been used in the generation of the list of essential pieces of information to be included in referral communication. These definitions are set out in the ISD Definitions and Codes for the NHS in Scotland ¹⁶ (available from Phil McNicol, Definitions and Standards Manager, Information and Statistics Division, Trinity Park House, South Trinity Road, Edinburgh EH5 3SQ).

While one particular format has been suggested in order to encourage a general uniformity of referral communication across Scotland, it is recognised that local areas and particular disciplines may wish to modify the template according to local circumstances or discipline-specific needs.

3.2 Information technology and electronic communication

Information Technology at several levels can support the implementation of the recommended referral letter. Each level brings further benefit to the speed and accuracy of the referral process. When considering the appropriate level for them, a practice needs to consider what will best suit their methods of working now and in the future. Key questions to be addressed include:

How can we save time and increase accuracy when producing the letters?

There are various ways of semi-automatically producing the forms/letters. At its simplest this means using a word-processing template with, for example, the practice code preset in the form. A more sophisticated method would be to cause the relevant patient's details to be automatically extracted from the practice system and inserted in the right place in the letter.

Contact your practice's system supplier for advice, preferably through User Groups so that preparatory work need only be done once and shared by all (this is the bonus of a Scotland wide standard format). This is already underway for the GPASS system.

What's the best way of getting the 'free text' into the letter?

Options are typing in of handwritten notes and tape dictation followed by audio-typing. The most futuristic - and potentially the most beneficial - is for GPSs to use voice dictation computer programs,meaning that the spoken work is automatically translated into typing which appears on the screen. The technology to do this has been disappointing and expensive until recently, but trials are underway of GPs using more modern and cheap programs.

How are we going to send the letters?

Options include 'surface' mail, fax,email, and 'structured' email. Clearly the latter three options reduce delay compared to traditional mail. Faxing is less secure and may have legibility problems. Email is becoming the option of choice with the installation of NHSnet connections in practices and Trusts, and this is being developed in several parts of Scotland. 'Structured' email refers to a special type of transmission (using electronic data interchange) which allows information from the incoming letter to be extracted and automatically put into waiting slots in the appropriate hospital system. Apart from saving re-typing at the hospital end, this brings considerable clinical benefits, e.g. making past medication details instantly available.

The training of staff in the use and transmission of the referral document is crucial. Technology without proper staff preparation and support is a waste of time.

3.3 Electronic referral document

This report on the recommended referral document is being made available in the traditional paper-based format which will allow practitioners to read, digest and implement it in their own timescale.

In addition, a software package has been commissioned by the NHS Management Executive which semi-automatically produces referral letters using the recommended template. The system can be set up to hold the practice letterhead details and is also capable of importing patient data from the practice system. [More information]

3.4 Opportunities for audit

The SIGN working group is aware that audit activity is an important method of ensuring quality in clinical care. It has been suggested that the referral letter provides a clinical window into the mind of the referring practitioner and that by extrapolation one can make assumptions about general clinical care ^{17,
18}. While this may be a tenuous link, audit of referral work will give an indication of how well general practitioners and other primary care professionals communicate with colleagues in secondary care.

The suggested template, irrespective of the actual format or mode of transmission, gives a valid "gold standard" for the minimum essential information which should be included in referral letters. Thus, audit of referral letters against this template will give an indication of the quality of referral communication between primary and secondary care. The SIGN working group recommends that this would be a suitable way to ensure quality in referral communication.