Ask yourself a question. How do referrals within the NHS work? The simple answer is that they are done via letter. Nothing more, nothing less, but the system is broken.
Doctors are human and they’re also under increased strain. As the complexity of a medical case increases, errors are more common. Doctors don’t have the time to dig deep into medical files to find the missing link. The effect can often be mistaken for cause as the number of notations increase, and while we don’t like to admit it, on occasion there are occasions where laziness in ensuring proper representation of clinical status can creep in, or information is often left out because a mistake has occurred.
This is something I have abundant knowledge about and can opine on, not just because I have helped numerous people with problems with NHS (particularly in the realm of delayed diagnosis) but because I have also witnessed it myself personally and with regards to my mother who I am a carer for.
The fact is that the entire system of referrals relies on trust. Trust by the patient that doctors will accurately reflect their clinical status. Trust from the doctors receiving the referral that all pertinent information is contained in the documentation, and trust that a second opinion can be rendered based on the empirical evidence.
In a recent referral from one board to another, not only was medication missed from it (which was highly pertinent to the referral) but also the medical issues those medications were used to treat. The receiving physician rendered an incorrect opinion based on faulty information which I caught. When he was furnished with the correct information the entire second opinion changed drastically.
This has to beg the question in an overstretched NHS: Can we rely on information to be passed back and forward correctly?
In another instance, there was a situation where a condition was caused as a result of the effects of an underlying condition, but after 5 years of failing to get a diagnosis, the caused condition was opined to have caused the underlying condition. The timeline obviously did not support the second opinion, but the damage was already done, doctors there-after opined based on faulty information because the previous information was not looked at in terms of its progression – this resulted in 12 years of the patient receiving the wrong medication which caused the medical decline. And again, it leads to the question of whether or not the current system of referrals actually works properly.
Incorrectly recorded information like medications etc could lead to more than misdiagnosis, if the receiving physician prescribes something based on faulty information, then they could end up killing the patient. This is a matter of serious concern.
As for second opinions themselves, they are not an automatic right of a patient, and it has been experienced (multiple times) that boards will actively fight a second opinion because of potential legal liability. I have personally witnessed this. My mother was diagnosed with cancer and refused a second opinion on surgery she was denied to remove the tumour because she M.S. A second opinion was blocked, faulty information given to the receiving physician leading them not to opine on the substance of the matter or do a full bedside review. A 5 months fight ensued where my mother ended up with two further infections and 5 months in hospital. When eventually forced to deliver a second opinion, another board found that the local board had accidentally misdiagnosed her with cancer.
This could have been avoided if an independent second opinion was an automatic right and there were checks and balances built into the system to ensure information passed from one board to another was accurate. The health secretary was about as useful as a jam sandwich to a drowning rabbit, despite the fact that it was a national policy issue straddling 3 health boards.
Which brings up the question, why was medication etc missed off a referral? The answer is simple – communications between doctors were done in hastily sent emails when they should have been done on a specialised referral platform which automatically attached the pertinent information to the referral.
I’m calling for a number of major reforms to the way second opinions are handled.
Firstly, I am calling on the right to a second opinion to be enshrined, and specialised provisions in serious matters of contention (which can be designated as such by the patient, not the health board). What I mean by that is, patients should have the right, where there is contention between the board and the patient, to have a second opinion delivered by another board, or away from the board currently in charge of the current medical processes. Where there is a complaint, those named in that complaint should have no ability to involve themselves in it (not just for the patient’s protection, but also for the medical staff’s protection). Consent should automatically be considered to have been withdrawn, and consent should be recognised to apply to both medical treatment and administrative matters concerned with medical treatment.
The second policy change I want to see is the synchronisation of medical information. This means that medications when changed at GP level, should automatically be updated at the hospital level and vice versus.
In addition, a timeline screen should be added to the system which contains current information and a timeline of the patient’s medical history – this should be AUTOMATICALLY attached by the system to EVERY referral.
Each referral should be standardised, the patient’s personal details at the top followed by their medications and followed by their medical timeline, with the request and notations of the doctor making the referral below. Medical records should not be an afterthought, they should be accessible to doctors dealing with a referral.
Doctors don’t have the time to make referrals meticulous, so why not make it an automatic function to include all pertinent information on a referral by automating the process. Make the communication between boards a clear standardised practice where there is no ability for information to be losed, omitted (by error or deliberately) and where every referral is of the same standard – this can only aid patients in getting faster diagnosis and treatment, and doctors receiving referrals in being able to make a sound second opinion based on complete empirical data.
The referral system needs a complete re-think, because in a world where human error is normal, and where the pressures of the current climate lead to such errors or omission, surely it should be incumbent on us to try and reduce possible errors and omissions, and to eleviate some of the burden from overworked doctors.