Pubfic Health (1992), 106, 429-436
© The Society of Public Health, 1992
A District Survey of Paediatric Outpatient Referrals C. M. Ni Bhrolch~in, MRCPI MRCGP
Paediatric Registrar, Arrowe Park Hospital, Upton, Wirral
A prospective analysis of general paediatric outpatient referrals to a district general hospital was conducted over four months. Because of geographical characteristics, this probably represents all referrals within the district during that time. The referral rate was 15.5 per thousand per annum. Only five children did not see a consultant at their first visit. One hundred and five children were discharged after one consultation. Communication between general practitioners and hospital appeared generally good. Although only 56 referral letters stated the urgency of referral, 351 (94%) stated a reason for referral. One hundred and five children could have been dealt with by the community child health service. The NHS reforms, fundholding practices and the development of the community child health service may profoundly affect current outpatient workloads and practice.
Introduction Interest in referrals to hospital has increased since the NHS reforms were introduced. Medical audit and fundholding practices may, in future, significantly alter referral patterns. There have been some studies of hospital workload prior to the changes, 1-3 but most referral studies have been based on individual or grouped practices. 4-8 Practices which agree to participate in such studies may not be truly representative of general practice as a whole. A literature search failed to find detailed studies of hospital paediatric outpatient referrals. Two previous studies had shown the benefits of consultant clinics held outside hospital 9'1° and Andrews et al. i1 had examined reasons for non-attendance at hospital clinics. Wirral is a peninsula situated across the Mersey from Liverpool. It is a geographically circumscribed area and, prior to the reforms, few paediatric referrals were made outside the district or to the district from outside it. All paediatric services were directed from one District General Hospital ( D G H ) although two peripheral clinics were also held by consultants from the D G H . The Wirral district was, therefore, ideally suited for a population-based study of hospital paediatric outpatient referrals. This included not only referrals from GPs but also other sources such as the A & E D e p a r t m e n t and community doctors.
Method The study was conducted over a four-month period prior to the NHS reforms: 1st February to 31st May 1988. All children who had been given appointments as new patients at a general paediatric clinic during the study period were included in the study. Correspondence to: Dr C. M. Nf Bhrolch~in, Child Development Centre, Northampton General Hospital, Northampton NN1 5BD.
430
C. M. Nf Bhrolchdin
The three consultant paediatricians in the district were based in Arrowe Park Hospital. Each consultant had two outpatient clinics a week at Arrowe Park. In addition one consultant did a clinic each week at Victoria Central Hospital and another had a weekly clinic at Clatterbridge Hospital. Both peripheral clinics were included in the study but specialist clinics held by visiting consultants were not. The agreed practice of the three consultants was that all referral letters were seen by them before an appointment was made. They decided how urgently the child should be seen and recorded this on the referral letter. An appointment was then arranged. All new patients should be seen by a consultant at their first visit. If a child failed to attend, a second appointment might be offered or the referring doctor informed and a further appointment made at their request. For the purposes of this study, children who failed to attend and were not offered a second appointment and those who failed their first but attended their second during the study period were included in the study. Children whose second appointment came after the end of the study period were excluded. After the child's appointment, the referral letter and case sheet was examined and the following information extracted: referring doctor, urgency stated by referring doctor, reason for referral, referring doctor's diagnosis, investigations done or treatment given prior to referral. The consultant's assessment of urgency was noted. Further information collected included the date of referral and date seen (waiting time), consultant diagnosis and the outcome of the first consultation. The consultant's letter to the referring doctor was also examined for replies to specific queries raised by the referring doctor. Results
There were 393 referrals during the four-month period. Thirteen children missed their first appointment and were given their second after the study period finished. These were excluded. Six case sheets were not available, leaving 374 referrals for analysis. There were 72,596 children under 15 living in the district at the time of the study. The referral rate was 15.5 per thousand children per annum (one in 66 children). Forty-nine children were under 1 year; 121 between 1 and 4; 116 between 5 and 9; 80 between 10 and 14; and eight over 15. There were 190 males and 184 females.
Urgency of appointments The urgency with which the appointment was required was stated in only 56 (15%) letters. Thirty-one requested an urgent appointment and the consultant agreed in 29. Twenty-five letters stated that a routine appointment was sufficient and the consultant agreed in all cases. The consultants considered that 24 of the remaining 318 children should be seen before the end of the waiting list. In six cases, the consultant had been contacted by telephone with a referral letter delivered by the patient at the consultation. Overall, 222 (59%) children were seen within eight weeks of referral but 45 (12% of the total) children waited longer than 12 weeks. Three children required admission before they could be seen in outpatients. They had waited three, four and eight weeks respectively. Another six children had their appointment brought forward: three by parents, two by the G P and the sixth by a health visitor. Forty-seven appointments (11.7% of those offered during the study period) were wasted due to
Paediatric Outpatient Referrals
431
non-attendance. Twenty-five children did not attend at all. This figure does not include cancellations (2) or admissions (3) when the appointments could be re-allocated.
Conditions diagnosed Conditions diagnosed are classified in Table I. Respiratory conditions included 48 children with asthma. Fifteen of the children with neurological conditions were referred with possible epilepsy and 14 with syncope. Epilepsy was confirmed in seven of the 13 new cases referred. The other two had had a recurrence of seizures after treatment had been discontinued. Fourteen children had recurrent headaches: 12 had migraine and two tension headaches. Most of those with gastro-intestinal complaints had diarrhoea (25) or vomiting (11). One child with diarrhoea had coeliac disease and one cystic fibrosis but most were considered to have recurrent gastroenteritis, toddler diarrhoea or specific food intolerances. Forty-five children were referred with murmurs and two-thirds of these were innocent. Pathological murmurs included VSD (8), ASD (2), aortic stenosis (2), pulmonary stenosis (1) and patent ductus arteriosus (1). Exactly half the pathological murmurs were detected by general practitioners apparently on opportunistic examination. Behaviour problems included 12 cases of enuresis, six with encopresis and seven with temper tantrums. The periodic syndrome group had 29 cases of recurrent abdominal pain and four with cyclical vomiting. Urinary problems included 18 children with suspected urinary infections. Thirteen had had a midstream urine test performed by the GP. Thirteen were referred after one infection and the others had had at least two episodes. Seventeen of these children were investigated and the other had been admitted to hospital prior to her appointment. Problems with both physical and mental development were included in the development category. They included 13 children with short stature (all constitutional) and five with abnormalities of sexual maturation. Three babies had possible problems with vision, global delay and hemiplegia but no older children with developmental delay were seen.
Table I Category Respiratory Neurological Cardiovascular Gastrointestinal Periodic syndrome Behaviour Total
Conditions diagnosed (some patients had more than one diagnosis) No. (%) of patients 74 49 48 48 33 31
(19.4) (12.8) (12.6) (12.6) (8.6) (8.1)
Category
No. (%) of patients
Development Urinary Rheumatological Infective Haematological Miscellaneous
28 (7.8) 26 (6.8) 11 (2.9) 10 (2.6) 9 (2.4) 15 (3.9) 382 (100)
C. M. N[ Bhrolchdin
432
Referral process The origin of referrals is shown in Table II. One hundred and ninety-six GPs practised in the catchment area at the time of the study and only one referral came from outside. Table III shows the n u m b e r of referrals per GP. Thirty referrals had originated in the c o m m u n i t y child health service but were channelled through the GP. A reason for referral was given in 351 (94%) letters. O n e was illegible. Details of the others are shown in Table IV. Twenty-four children were re-referrals of children who had previously been seen by the consultant and discharged back to the G P for follow-up. One hundred and ninety-one (51%) letters a t t e m p t e d a diagnosis and 146 (76%) were correct. Seventeen of the 37 incorrect diagnoses were felt to be justified suspicions or were excluded only after hospital investigations, e.g. sweat chlorides or EEG. Seventy-eight (21%) children had some investigation p e r f o r m e d prior to referral and the result was usually given in the referral letter. These were mainly simple tests, TableII Origin of referrals (two children had no referral letter and could not be assigned to a referral agency) Origin of referrals
No. (%) of referrals
General practitioners Clinical medical officers (direct) Other consultants A&E Dept Trainee/assistant GPs Locum GPs Transfer of care Adoption Society
333 (89.5) 14 (3.8) 8 5 5 4 2 1
(2.1) (1.3) (1.3) (1.1) (0.6) (0.3)
Total
372
(100)
Table III No. of referrals None 1
2 3 4 5 6 7 8 9
Number of referrals per GP principal No. of GPs 58 58 40 14 7 10 5 l 2
10
11 Total
2 197
Paediatric Outpatient Referrals
433
Table IV Reasons given for referral (some letters gave more than one reason) Reason given
No. (%)
Make diagnosis Advice on treatment Investigation Confirm diagnosis Parental anxiety Miscellaneous Not stated
138 57 56 50 50 7 23
(36.2) (15.0) (14.7) (13.1) (13.1) (1.8) (6.0)
Total
381 (100)
e.g. full blood count, midstream urine and chest X-ray. One hundred and twenty (32%) had received some treatment before referral. It was felt that 17 children might have benefited from some attempt at treatment before referral. T h e y included five with asthma and four with enuresis who had apparently not received even simple treatment prior to referral.
Outcome of first consultation The outcome of the first consultation is shown in Figure 1. Details of tertiary referrals are given in Table V. Looking at re-referrals, 13 had further investigations performed, treatment was changed in five and five were referred on to a regional referral centre. No action was taken in four cases and two did not attend. Ninety-one letters asked specific questions about management and these were answered in all but three cases.
Discussion Because of the geographical characteristics of Wirral, the referral rate in this study probably represents a true population-based referral rate. It includes eight children over 15 whose problems were perceived as paediatric, e.g. pubertal delay, short stature. It reflects working practice in a district general hospital. The variation in individual GPs' referral rates already shown for other disciplines is confirmed for paediatrics.4,5,6,12't3 Communication between GPs and hospitals has been examined before.~4,15 Nearly all GPs in this study gave a reason for referral, confirming a previous orthopaedic study from Nottingham. 14 Paediatricians were rather better than their counterparts at answering GPs' questions (97% vs 44%). Wirral GPs seldom stated the urgency of referral but, when they did, their assessment was nearly always accepted. In Nottingham it made no difference to waiting time for appointments. 14 Wirral GPs were also willing to re-refer children for further management when required. The high rate of intervention shows their assessment was usually correct. Thus, communication between hospital and general practice seemed quite good in this district. General practitioners referring children knew they would be seen by a
C. M. N i Bhrolchdin
434
Children included in the study 374
I
Seen as outpatienti 344
J
Seen by registrar
None discharged I Admitted I
j Seen b~3~onsultant i
Started or changed treatment
Discharged
105
Admitted
48
Referred to other services Figure I
Table V
5
Investigated as outpatient
24
155
Outcome of first consultation
Number of tertiary referrals after first consultation
Service to which referred Surgery Child psychia try/psychology Cardiology ENT/audiology Ophthalmology Endocrinology Miscellaneous (HV, social services, physio) Total
No. of children 6 5 3 3 l 1 5 24
Paediatric Outpatient Referrals
435
consultant. The discharge rate also compares favourably with other consultant clinics. 9,1° This practice is by no means universal. In Nottingham, only half the letters were written by consultants.14 Another study found that only nine of 19 consultants had a policy of seeing new patients themselves. 3 Fundholding GPs may demand consultant opinions which may be more cost-effective. The new GP contract may also have implications for other aspects of D G H work. The most common condition referred was asthma (48). As GPs are now encouraged to hold their own 'mini-clinics' for asthma patients, will this change referral rates? Although nearly all GPs had explicitly (37) or implicitly (8) made the diagnosis, 13 had asked for confirmation of the diagnosis and 26 for advice on treatment. Forty-two children had started simple symptomatic treatment but 21 were started on regular prophylaxis after their first hospital consultation. Only eight children were discharged after one visit. A lack of confidence amongst at least some GPs in treating asthma in children may allow little reduction in referral rates despite the advent of 'mini-clinics' within practices. Eighteen children were referred with urinary tract infections. This raises the question of open access for GPs to ultrasound scanning, now the first-line investigation for children with urinary infection. Open access in other areas of work does not lead to inappropriate referrals a6'17 and may reduce clinic referrals. 17 Clear guidelines on subsequent management would have to be agreed as deficiencies have been shown in GP, and indeed hospital management of children with urinary infections, i8 The interface between community and hospital paediatrics is also changing. The 'community-type' referrals in this study showed an interesting pattern. There was no consultant community paediatrician in post at the time of the study but there was an active community service and enuresis service. One hundred and five children were referred with problems which could, in the author's opinion, have been dealt with by the community services, with access to hospital investigations. Sixty-four were referred by GPs, 38 directly or indirectly from CMOs and three from other agencies. This group includes all heart murmurs, behaviour problems, enuresis and developmental problems found during child health surveillance and other assessments. After initial assessment, some children would obviously be referred to hospital services but many could be treated by community services without referral, e.g. enuresis, behaviour problems. Nearly all the enuresis and behaviour problems were referred by GPs who may not have been aware of the community services available. A large proportion of CMO referrals, on the other hand, were for findings from surveillance, e.g. heart murmurs, developmental problems. The current changes in child health surveillance and community services in general may significantly change referral patterns in this area of work, though it is difficult to predict accurately which direction such a change will take. Finally, it is interesting to note the contribution of parental anxiety to hospital referral. Parental anxiety was stated as the sole (44) or additional (6) reason for referral in 50 cases, 13% of all referrals. Serious treatable illnesses were found in three children: a patent ductus arteriosus, cystic fibrosis and coeliac disease. The presentation in each case was somewhat atypical. Thus, in certain instances, parental anxiety may be a valid reason for referral. In the wake of the new contract and the NHS reforms more information on referrals will become available. This study, conducted prior to the changes, provides a valuable baseline for future comparison.
436
C. M. N[ Bhrolchdin
Acknowledgements 1 would like to thank Drs J. Seager, P. J. Todd and P. W. Wilkinson for their help and encouragement, and for allowing their work to be audited in this way.
References 1. Harrison, R. J., Wild, J. M. & Hobley, A. J. (1988). Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. British Medical Journal, 297, 1162-1167. 2. Yu-dong, W., Thompson, J. R., Goulstine, D. B. & Rosenthal, A. R. (1990). A survey of the inital referral of children to an ophthalmology department. British Journal of Ophthalmology, 74,650-653. 3. Kiff, R. S. & Sykes, P. A. (1988). Who undertakes the consultations in the outpatient department7 British Medical Journal, 296, 1511-1512. 4. Wilkin, D. & Smith, A. G. (1987). Variation in general practitioners' referral rates to consultants. Journal of the Royal College of General Practitioners, 37,350-353. 5. Wijkel, D. (1986). Encouraging the development of integrated health centres: a critical analysis of lower referral rates. Social Science and Medicine 23(1), 35-41. 6. Marinker, M., Wilkin, D. & Metcalfe, D. H. (1988). Referral to hospital: can we do better? British Medical Journal, 297: 461-464. 7. Pearson, C. R. (1988). General. practitioner referral rates. British Medical Journal, 297, 739-740. 8. Coulter, A., Noone, A. & Goldacre, M. (1989). General practitioners' referrals to specialist outpatient clinics. British Medical Journal, 299,304-308. 9. Marsh, G. N. & Tompkins, A. B. (1969). Paediatric care in general practice: an experiment in collaboration. British Medical Journal, i, 106-108. 10. Weller, S. D. V. (1975). Peripheral paediatric clinics: survey and medical audit. British Medical Journal, ii, 390-393. 11. Andrews, R., Morgan, J. D., Addy, D. P. & McNeish, A. S. (1990). Understanding non-attendance in outpatient paediatric clinics. Archives of Disease in Childhood, 65, 192-195. 12. Roland, M. & Morris, R. (1988). Are referrals by general practitioners influenced by the availability of consultants? British Medical Journal, 297,599-600. 13. Moore, A. T. & Roland, M. O. (1989). How much variation in referral rates among general practitioners is due to chance? British Medical Journal, 298,500-502. 14. Jacobs, L. G. H. & Pringle, M. A. (1990). Referral letters and replies from orthopaedic departments: opportunities missed. British Medical Journal 301,470-473. 15. Westerman, R. F., Hull, F. M., Bezemar, B. D. & Gort, G. (1990). A study of communication between general practitioners and specialists. British Journal of General Practice, 40,445-449. 16. Kalra, L., Price, W. R., Jones, B. J. M. & Hamlyn, A. N. (1988). Open access fibre sigmoidoscopy: a comparative audit of efficacy. British Medical Journal, 296, 1095-1096. 17. Wright, C. H. & Row, H. G. (1989). Access to radiology. Update, 38, 1134-1139. 18. South Bedfordshire Practitioners' Group (1990). Development of renal scars in children: missed opportunities in management. British Medical Journal, 301, 1082-1084.
© The Society of Public Health, 1992
A District Survey of Paediatric Outpatient Referrals C. M. Ni Bhrolch~in, MRCPI MRCGP
Paediatric Registrar, Arrowe Park Hospital, Upton, Wirral
A prospective analysis of general paediatric outpatient referrals to a district general hospital was conducted over four months. Because of geographical characteristics, this probably represents all referrals within the district during that time. The referral rate was 15.5 per thousand per annum. Only five children did not see a consultant at their first visit. One hundred and five children were discharged after one consultation. Communication between general practitioners and hospital appeared generally good. Although only 56 referral letters stated the urgency of referral, 351 (94%) stated a reason for referral. One hundred and five children could have been dealt with by the community child health service. The NHS reforms, fundholding practices and the development of the community child health service may profoundly affect current outpatient workloads and practice.
Introduction Interest in referrals to hospital has increased since the NHS reforms were introduced. Medical audit and fundholding practices may, in future, significantly alter referral patterns. There have been some studies of hospital workload prior to the changes, 1-3 but most referral studies have been based on individual or grouped practices. 4-8 Practices which agree to participate in such studies may not be truly representative of general practice as a whole. A literature search failed to find detailed studies of hospital paediatric outpatient referrals. Two previous studies had shown the benefits of consultant clinics held outside hospital 9'1° and Andrews et al. i1 had examined reasons for non-attendance at hospital clinics. Wirral is a peninsula situated across the Mersey from Liverpool. It is a geographically circumscribed area and, prior to the reforms, few paediatric referrals were made outside the district or to the district from outside it. All paediatric services were directed from one District General Hospital ( D G H ) although two peripheral clinics were also held by consultants from the D G H . The Wirral district was, therefore, ideally suited for a population-based study of hospital paediatric outpatient referrals. This included not only referrals from GPs but also other sources such as the A & E D e p a r t m e n t and community doctors.
Method The study was conducted over a four-month period prior to the NHS reforms: 1st February to 31st May 1988. All children who had been given appointments as new patients at a general paediatric clinic during the study period were included in the study. Correspondence to: Dr C. M. Nf Bhrolch~in, Child Development Centre, Northampton General Hospital, Northampton NN1 5BD.
430
C. M. Nf Bhrolchdin
The three consultant paediatricians in the district were based in Arrowe Park Hospital. Each consultant had two outpatient clinics a week at Arrowe Park. In addition one consultant did a clinic each week at Victoria Central Hospital and another had a weekly clinic at Clatterbridge Hospital. Both peripheral clinics were included in the study but specialist clinics held by visiting consultants were not. The agreed practice of the three consultants was that all referral letters were seen by them before an appointment was made. They decided how urgently the child should be seen and recorded this on the referral letter. An appointment was then arranged. All new patients should be seen by a consultant at their first visit. If a child failed to attend, a second appointment might be offered or the referring doctor informed and a further appointment made at their request. For the purposes of this study, children who failed to attend and were not offered a second appointment and those who failed their first but attended their second during the study period were included in the study. Children whose second appointment came after the end of the study period were excluded. After the child's appointment, the referral letter and case sheet was examined and the following information extracted: referring doctor, urgency stated by referring doctor, reason for referral, referring doctor's diagnosis, investigations done or treatment given prior to referral. The consultant's assessment of urgency was noted. Further information collected included the date of referral and date seen (waiting time), consultant diagnosis and the outcome of the first consultation. The consultant's letter to the referring doctor was also examined for replies to specific queries raised by the referring doctor. Results
There were 393 referrals during the four-month period. Thirteen children missed their first appointment and were given their second after the study period finished. These were excluded. Six case sheets were not available, leaving 374 referrals for analysis. There were 72,596 children under 15 living in the district at the time of the study. The referral rate was 15.5 per thousand children per annum (one in 66 children). Forty-nine children were under 1 year; 121 between 1 and 4; 116 between 5 and 9; 80 between 10 and 14; and eight over 15. There were 190 males and 184 females.
Urgency of appointments The urgency with which the appointment was required was stated in only 56 (15%) letters. Thirty-one requested an urgent appointment and the consultant agreed in 29. Twenty-five letters stated that a routine appointment was sufficient and the consultant agreed in all cases. The consultants considered that 24 of the remaining 318 children should be seen before the end of the waiting list. In six cases, the consultant had been contacted by telephone with a referral letter delivered by the patient at the consultation. Overall, 222 (59%) children were seen within eight weeks of referral but 45 (12% of the total) children waited longer than 12 weeks. Three children required admission before they could be seen in outpatients. They had waited three, four and eight weeks respectively. Another six children had their appointment brought forward: three by parents, two by the G P and the sixth by a health visitor. Forty-seven appointments (11.7% of those offered during the study period) were wasted due to
Paediatric Outpatient Referrals
431
non-attendance. Twenty-five children did not attend at all. This figure does not include cancellations (2) or admissions (3) when the appointments could be re-allocated.
Conditions diagnosed Conditions diagnosed are classified in Table I. Respiratory conditions included 48 children with asthma. Fifteen of the children with neurological conditions were referred with possible epilepsy and 14 with syncope. Epilepsy was confirmed in seven of the 13 new cases referred. The other two had had a recurrence of seizures after treatment had been discontinued. Fourteen children had recurrent headaches: 12 had migraine and two tension headaches. Most of those with gastro-intestinal complaints had diarrhoea (25) or vomiting (11). One child with diarrhoea had coeliac disease and one cystic fibrosis but most were considered to have recurrent gastroenteritis, toddler diarrhoea or specific food intolerances. Forty-five children were referred with murmurs and two-thirds of these were innocent. Pathological murmurs included VSD (8), ASD (2), aortic stenosis (2), pulmonary stenosis (1) and patent ductus arteriosus (1). Exactly half the pathological murmurs were detected by general practitioners apparently on opportunistic examination. Behaviour problems included 12 cases of enuresis, six with encopresis and seven with temper tantrums. The periodic syndrome group had 29 cases of recurrent abdominal pain and four with cyclical vomiting. Urinary problems included 18 children with suspected urinary infections. Thirteen had had a midstream urine test performed by the GP. Thirteen were referred after one infection and the others had had at least two episodes. Seventeen of these children were investigated and the other had been admitted to hospital prior to her appointment. Problems with both physical and mental development were included in the development category. They included 13 children with short stature (all constitutional) and five with abnormalities of sexual maturation. Three babies had possible problems with vision, global delay and hemiplegia but no older children with developmental delay were seen.
Table I Category Respiratory Neurological Cardiovascular Gastrointestinal Periodic syndrome Behaviour Total
Conditions diagnosed (some patients had more than one diagnosis) No. (%) of patients 74 49 48 48 33 31
(19.4) (12.8) (12.6) (12.6) (8.6) (8.1)
Category
No. (%) of patients
Development Urinary Rheumatological Infective Haematological Miscellaneous
28 (7.8) 26 (6.8) 11 (2.9) 10 (2.6) 9 (2.4) 15 (3.9) 382 (100)
C. M. N[ Bhrolchdin
432
Referral process The origin of referrals is shown in Table II. One hundred and ninety-six GPs practised in the catchment area at the time of the study and only one referral came from outside. Table III shows the n u m b e r of referrals per GP. Thirty referrals had originated in the c o m m u n i t y child health service but were channelled through the GP. A reason for referral was given in 351 (94%) letters. O n e was illegible. Details of the others are shown in Table IV. Twenty-four children were re-referrals of children who had previously been seen by the consultant and discharged back to the G P for follow-up. One hundred and ninety-one (51%) letters a t t e m p t e d a diagnosis and 146 (76%) were correct. Seventeen of the 37 incorrect diagnoses were felt to be justified suspicions or were excluded only after hospital investigations, e.g. sweat chlorides or EEG. Seventy-eight (21%) children had some investigation p e r f o r m e d prior to referral and the result was usually given in the referral letter. These were mainly simple tests, TableII Origin of referrals (two children had no referral letter and could not be assigned to a referral agency) Origin of referrals
No. (%) of referrals
General practitioners Clinical medical officers (direct) Other consultants A&E Dept Trainee/assistant GPs Locum GPs Transfer of care Adoption Society
333 (89.5) 14 (3.8) 8 5 5 4 2 1
(2.1) (1.3) (1.3) (1.1) (0.6) (0.3)
Total
372
(100)
Table III No. of referrals None 1
2 3 4 5 6 7 8 9
Number of referrals per GP principal No. of GPs 58 58 40 14 7 10 5 l 2
10
11 Total
2 197
Paediatric Outpatient Referrals
433
Table IV Reasons given for referral (some letters gave more than one reason) Reason given
No. (%)
Make diagnosis Advice on treatment Investigation Confirm diagnosis Parental anxiety Miscellaneous Not stated
138 57 56 50 50 7 23
(36.2) (15.0) (14.7) (13.1) (13.1) (1.8) (6.0)
Total
381 (100)
e.g. full blood count, midstream urine and chest X-ray. One hundred and twenty (32%) had received some treatment before referral. It was felt that 17 children might have benefited from some attempt at treatment before referral. T h e y included five with asthma and four with enuresis who had apparently not received even simple treatment prior to referral.
Outcome of first consultation The outcome of the first consultation is shown in Figure 1. Details of tertiary referrals are given in Table V. Looking at re-referrals, 13 had further investigations performed, treatment was changed in five and five were referred on to a regional referral centre. No action was taken in four cases and two did not attend. Ninety-one letters asked specific questions about management and these were answered in all but three cases.
Discussion Because of the geographical characteristics of Wirral, the referral rate in this study probably represents a true population-based referral rate. It includes eight children over 15 whose problems were perceived as paediatric, e.g. pubertal delay, short stature. It reflects working practice in a district general hospital. The variation in individual GPs' referral rates already shown for other disciplines is confirmed for paediatrics.4,5,6,12't3 Communication between GPs and hospitals has been examined before.~4,15 Nearly all GPs in this study gave a reason for referral, confirming a previous orthopaedic study from Nottingham. 14 Paediatricians were rather better than their counterparts at answering GPs' questions (97% vs 44%). Wirral GPs seldom stated the urgency of referral but, when they did, their assessment was nearly always accepted. In Nottingham it made no difference to waiting time for appointments. 14 Wirral GPs were also willing to re-refer children for further management when required. The high rate of intervention shows their assessment was usually correct. Thus, communication between hospital and general practice seemed quite good in this district. General practitioners referring children knew they would be seen by a
C. M. N i Bhrolchdin
434
Children included in the study 374
I
Seen as outpatienti 344
J
Seen by registrar
None discharged I Admitted I
j Seen b~3~onsultant i
Started or changed treatment
Discharged
105
Admitted
48
Referred to other services Figure I
Table V
5
Investigated as outpatient
24
155
Outcome of first consultation
Number of tertiary referrals after first consultation
Service to which referred Surgery Child psychia try/psychology Cardiology ENT/audiology Ophthalmology Endocrinology Miscellaneous (HV, social services, physio) Total
No. of children 6 5 3 3 l 1 5 24
Paediatric Outpatient Referrals
435
consultant. The discharge rate also compares favourably with other consultant clinics. 9,1° This practice is by no means universal. In Nottingham, only half the letters were written by consultants.14 Another study found that only nine of 19 consultants had a policy of seeing new patients themselves. 3 Fundholding GPs may demand consultant opinions which may be more cost-effective. The new GP contract may also have implications for other aspects of D G H work. The most common condition referred was asthma (48). As GPs are now encouraged to hold their own 'mini-clinics' for asthma patients, will this change referral rates? Although nearly all GPs had explicitly (37) or implicitly (8) made the diagnosis, 13 had asked for confirmation of the diagnosis and 26 for advice on treatment. Forty-two children had started simple symptomatic treatment but 21 were started on regular prophylaxis after their first hospital consultation. Only eight children were discharged after one visit. A lack of confidence amongst at least some GPs in treating asthma in children may allow little reduction in referral rates despite the advent of 'mini-clinics' within practices. Eighteen children were referred with urinary tract infections. This raises the question of open access for GPs to ultrasound scanning, now the first-line investigation for children with urinary infection. Open access in other areas of work does not lead to inappropriate referrals a6'17 and may reduce clinic referrals. 17 Clear guidelines on subsequent management would have to be agreed as deficiencies have been shown in GP, and indeed hospital management of children with urinary infections, i8 The interface between community and hospital paediatrics is also changing. The 'community-type' referrals in this study showed an interesting pattern. There was no consultant community paediatrician in post at the time of the study but there was an active community service and enuresis service. One hundred and five children were referred with problems which could, in the author's opinion, have been dealt with by the community services, with access to hospital investigations. Sixty-four were referred by GPs, 38 directly or indirectly from CMOs and three from other agencies. This group includes all heart murmurs, behaviour problems, enuresis and developmental problems found during child health surveillance and other assessments. After initial assessment, some children would obviously be referred to hospital services but many could be treated by community services without referral, e.g. enuresis, behaviour problems. Nearly all the enuresis and behaviour problems were referred by GPs who may not have been aware of the community services available. A large proportion of CMO referrals, on the other hand, were for findings from surveillance, e.g. heart murmurs, developmental problems. The current changes in child health surveillance and community services in general may significantly change referral patterns in this area of work, though it is difficult to predict accurately which direction such a change will take. Finally, it is interesting to note the contribution of parental anxiety to hospital referral. Parental anxiety was stated as the sole (44) or additional (6) reason for referral in 50 cases, 13% of all referrals. Serious treatable illnesses were found in three children: a patent ductus arteriosus, cystic fibrosis and coeliac disease. The presentation in each case was somewhat atypical. Thus, in certain instances, parental anxiety may be a valid reason for referral. In the wake of the new contract and the NHS reforms more information on referrals will become available. This study, conducted prior to the changes, provides a valuable baseline for future comparison.
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C. M. N[ Bhrolchdin
Acknowledgements 1 would like to thank Drs J. Seager, P. J. Todd and P. W. Wilkinson for their help and encouragement, and for allowing their work to be audited in this way.
References 1. Harrison, R. J., Wild, J. M. & Hobley, A. J. (1988). Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. British Medical Journal, 297, 1162-1167. 2. Yu-dong, W., Thompson, J. R., Goulstine, D. B. & Rosenthal, A. R. (1990). A survey of the inital referral of children to an ophthalmology department. British Journal of Ophthalmology, 74,650-653. 3. Kiff, R. S. & Sykes, P. A. (1988). Who undertakes the consultations in the outpatient department7 British Medical Journal, 296, 1511-1512. 4. Wilkin, D. & Smith, A. G. (1987). Variation in general practitioners' referral rates to consultants. Journal of the Royal College of General Practitioners, 37,350-353. 5. Wijkel, D. (1986). Encouraging the development of integrated health centres: a critical analysis of lower referral rates. Social Science and Medicine 23(1), 35-41. 6. Marinker, M., Wilkin, D. & Metcalfe, D. H. (1988). Referral to hospital: can we do better? British Medical Journal, 297: 461-464. 7. Pearson, C. R. (1988). General. practitioner referral rates. British Medical Journal, 297, 739-740. 8. Coulter, A., Noone, A. & Goldacre, M. (1989). General practitioners' referrals to specialist outpatient clinics. British Medical Journal, 299,304-308. 9. Marsh, G. N. & Tompkins, A. B. (1969). Paediatric care in general practice: an experiment in collaboration. British Medical Journal, i, 106-108. 10. Weller, S. D. V. (1975). Peripheral paediatric clinics: survey and medical audit. British Medical Journal, ii, 390-393. 11. Andrews, R., Morgan, J. D., Addy, D. P. & McNeish, A. S. (1990). Understanding non-attendance in outpatient paediatric clinics. Archives of Disease in Childhood, 65, 192-195. 12. Roland, M. & Morris, R. (1988). Are referrals by general practitioners influenced by the availability of consultants? British Medical Journal, 297,599-600. 13. Moore, A. T. & Roland, M. O. (1989). How much variation in referral rates among general practitioners is due to chance? British Medical Journal, 298,500-502. 14. Jacobs, L. G. H. & Pringle, M. A. (1990). Referral letters and replies from orthopaedic departments: opportunities missed. British Medical Journal 301,470-473. 15. Westerman, R. F., Hull, F. M., Bezemar, B. D. & Gort, G. (1990). A study of communication between general practitioners and specialists. British Journal of General Practice, 40,445-449. 16. Kalra, L., Price, W. R., Jones, B. J. M. & Hamlyn, A. N. (1988). Open access fibre sigmoidoscopy: a comparative audit of efficacy. British Medical Journal, 296, 1095-1096. 17. Wright, C. H. & Row, H. G. (1989). Access to radiology. Update, 38, 1134-1139. 18. South Bedfordshire Practitioners' Group (1990). Development of renal scars in children: missed opportunities in management. British Medical Journal, 301, 1082-1084.
