Health boards across Wales reject more than 115,000 GP referrals
HEALTH boards across Wales rejected more than 115,000 referrals from GPs during the first 11 months of 2022, we can reveal.
The astonishingly high figure became apparent from a series of information disclosures to the Western Mail and has led to concerns that waiting-lists for hospital treatment – already at high levels – might be even longer if some of the rejected referrals were counted.
In December we asked all seven health boards how many referrals to specialist/secondary care outpatient teams from GPs had been rejected in 2019 and between January and November 2022.
Across Wales the number of rejected referrals totalled at least 88,949 in 2019 and at least 115,292 during 2022, excluding December.
We also asked the health boards which three outpatient services had seen the highest number of referral rejections.
Some of the health boards gave reasons for the rejections, while others did not:
Aneurin Bevan University Health Board (UHB) said: “Numbers for ophthalmology are high due to the referral route being the only access for primary care to send information, therefore a large number of referrals are received for information only.
“For example, every cataract surgery carried out will generate an optometry review which is sent in to the health board for information and no action is required. This will then appear as a referral that is rejected.
“Ophthalmology also have a large number of requests for expediting surgery for patients already within the system. Therefore, the current referral process provides a false impression of the number of actual referrals received and how many subsequently rejected.
“Electronic referral systems are being established throughout ophthalmology on a national level and the health board is fully engaged with this process in order to introduce the systems as soon as they are available and safe to use.
“This system will help improve the communication lines between primary and secondary care.”
Cardiff and Vale: Rejection covers the following circumstances:
■ Referrals can be “rejected” if they are duplicate referrals – the patient has already been referred for the same conditions/concern. Long waiting-lists do lead to an increase in duplicate referrals;
■ referrals can be “rejected” if they are not in line with ‘interventions not normally undertaken’ (INNUs). The NHS has historically identified marginally effective and ineffective interventions/treatments (procedures and medicines that are deemed to have limited or no clinical value) and these healthcare interventions are termed INNUs. Such referrals are sent back to GPs stating that they are INNUs and the referrer given appropriate advice and guidance;
■ referrals can be “rejected” or returned in line with agreed pathways, for example, if an agreed pathway is for a patient to have had a certain diagnostic test before seeing the consultant. Again, these referrals are returned with this advice and guidance; and/or
■ referrals can be “rejected” or returned if they have insufficient or
incomplete information on them from the referrer.
Cwm Taf Morgannwg UHB offered no explanation, but stated that in 2022 the three services with the most rejected referrals were cardiology, child and adolescent mental health services and general surgery.
Hywel Dda UHB also offered no explanation but said the three outpatient services with the highest number of returned referrals between April and November 2022 were cardiology, dermatology and gastroenterology.
Swansea Bay UHB said: “A referral may be marked as ‘inappropriate’ for some of the following reasons:
■ Advice is given to the referrer without an appointment for the patient being required; therefore although the patient’s referral is marked as ‘returned’ or ‘inappropriate’, the health concern has still been addressed by clinicians without direct patient contact/appointment;
■ inadequate information supplied or inadequate assessment performed prior to referral; and/or
■ changes to referral criteria, therefore referrals are being returned to the GP with further advice/guidance.
In the first 11 months of 2022, 20% of all referrals received from GPs in the Swansea Bay UHB area were rejected.
Powys Teaching Health Board offered no explanation, but said that in 2022 the three outpatient services with the highest number of referral rejections were physiotherapy, dietetics and occupational therapy.
Betsi Cadwaladr University Health Board said it did not collect statistics of the kind sought.
Collating the information would cost £151,725 in employees’ time which would be chargeable to the Western Mail.
Welsh Conservative shadow health minister Russell George said: “It does seem that there is often a disconnect between different parts of our health service which is surely not helping patients and leaving staff chasing paper trails.
“It also seems that Wales’ recordlong waiting-list – where 50,000 people are still waiting over two years for NHS treatment – is further clogging up the referrals system.
“While health boards have provided some reasons for referral rejection, the scale of the issue means there is a systemic blockage in the system which could have some really adverse effects. I think the minister needs to investigate this as part of any plan to see the NHS recover from its crisis.”
Rhun ap Iorwerth, Plaid Cymru spokesman for health and care, said: “What’s clear from the number of
referrals not resulting in a patient pathway progressing, is that more can be done to improve the way primary and secondary care systems link up.
“Being able to track the patient’s journey, keeping quality data, and improving communication between the GP, the patient and secondary care are all vital if we’re to really understand the scale of waiting-lists and the pressures on the health system.”
Welsh Liberal Democrat leader Jane Dodds said: “The evidence presented here seems to show a significant lack of clarity in the system and could even mean waiting-lists are being under-reported.
“It is not acceptable that patients could be getting stuck in limbo between their GPs and health boards while continuing to suffer from illhealth. It’s also not clear how the Welsh Government can be confident in its planning if inconsistencies like this exist.”
British Medical Association Cymru general practitioners committee chairman Gareth Oelmann and consultants committee chairman Dr Stephen Kelly said in a joint statement: “It is concerning to see a significant rise in the number of rejected referrals across Wales but the reality is much more complex and so we would urge caution around interpreting the data.
“This is because the phrase ‘rejected referral’ is problematic; it is often used to categorise re-routed patient care, a duplicated referral or when the result of a diagnostic test has precluded the need for a consultation.
“For example, a consultant may look at a referral, recommend a CT scan, and the results of this may then determine a different treatment path.
“While this might be categorised as a rejected referral, in reality the care plan has taken a different course, although this is not to say that the current systems for referral are without issues.
“The changing development of clinical pathways which have been designed without input from GPs has led to confusion and delays for patients and urgent clarifications are needed to address the issue.
“We have raised this as an urgent matter with the Welsh Government and health board representatives and we’re now involved in trying to ensure pathways are standardised and appropriately developed in conjunction with GPs, where resource and workload implications are considered, and there is national governance of these pathways”
A Welsh Government spokeswoman said: “Latest statistics show that around 400,000 consultations [not including maternity or mental health services] were carried out in secondary care in Wales during November. Where a referral is not appropriate, GPs will discuss a suitable treatment plan of care with their patients.
“Work is also under way to embed the support tools to enable GPs to work with consultants more closely.
“These include special advice and guidance, e-referral and E advice, which aim to ensure patients’ needs are effectively managed and to improve the patient’s care and experience.”