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  • Patient referrals and waiting lists: A ticking time bomb

    Jerome P


    Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.


    It’s been a really difficult time for all of us this past year. When I say ‘we’, I mean every single person on the planet. I am yet to find anyone who hasn’t had to deal with stress, mental health problems, anxiety, illness, disappointment or bereavement of some nature over the past year.

    Collectively, we are all going to need a period to heal. I fear that the healthcare system will have no time to heal and that we are only on the tip of what more there is to come.

    Not only has the healthcare system had to deal with a pandemic, we have had to deal with the consequences from that. The backlog of operations that have been cancelled, the mental health crisis that has arisen out of an already underfunded system which is now overwhelmed, NHS staffing issues, holes in social care, the pressures on primary care and the ambulance services – these are all recognised as huge issues that are affecting patients.

    I want to highlight the problems that will rear their ugly heads in the coming few months and years to come and, possibly, cripple the NHS. I don’t know how we will deal with them.

    I want to push for guidance and support from NHS England as this will impact the governance of patient safety.

    Increase in serious incidents and never events

    As a patient safety manager, part of my role is being involved in investigations and supporting the clinical teams to undertake a root cause analysis of the incident. 

    In the Trust where I work, we pride ourselves on being open and honest and have a healthy reporting culture. Never has reporting been as important as now. We are learning all the time – we are working in new ways, electronic systems are rapidly taking over many face to face meetings and consultations. If we don’t know the problems, we won’t be able to improve. To add to that, the Trust has never been so busy, so stretched, so tired – so mistakes will be made.

    With this culture of reporting, the serious incidents and never events are exposed, as an increase in activity, staff redeployments, different areas of the hospital being used as ITUs or repurposed give rise to incidents. Human factors surely must be the largest contributing factor of why incidents are occurring at present.

    This give me an uneasy feeling that governance systems are going to be under enormous pressure in the coming years. I am starting to see some of the fall out already.

    There has been an increase in ‘lost to follow up’ where I work. This is when a patient is referred to a service for a consultation; for example, if a patient has a long term condition such as diabetes and they need follow up for podiatry a referral is made. The referral is picked up and appointment made accordingly. This may mean that a patient needs to be seen in two weeks, three months – depending on the urgency.

    Referrals getting lost

    So why are referrals getting lost? Here are a few reasons:

    • Many of our staff have been redeployed, either to vaccine hubs or to support the wards with admin tasks. Staff do not always know the procedures and protocols they need to work to and referrals don’t get actioned.
    • Administrative staff have taken on extra roles to reduce back log and work either extra hours or take on extra responsibilities. Paperwork will get missed, handovers won’t get done or in a timely way.
    • Staff are tired. Morale is at an all-time low. They cannot work harder or quicker. Juggling too much work means mistakes will be made.
    • We are using new systems to accommodate different ways of working, often with interim staff navigating this. Staff won’t be clear what is needed, maybe new systems will have teething problems that won’t be spotted, alerts and follow ups won’t be flagged or actioned. The volume of work has increased and, due to long waits, acuity of patients has increased. Changes in patients acuity might not be flagged or responded to so that urgent priorities might not be actioned.

    ‘Died on the waiting list’

    The second increase has been ‘died on the waiting list’. Patients waiting for bowel surgery, vascular surgery etc. These patients are seen in clinic by the specialty and placed on the waiting list. While on the waiting list their condition may get worse. At present there is no systematic way of monitoring patients on this list. If there is no way of monitoring them there is no system of triaging them and getting them to surgery at an appropriate time. 

    Patients are dying while on waiting lists. What is worse… we don’t know about this until we invite them for surgery.

    Each and every ‘lost to follow up’ or ‘died on the waiting list’ that has occurred is investigated. Currently, every Trust in the UK has 60 days to complete a root cause analysis and put actions in place for it not to happen again.

    In usual times, this would be achieved. Many governance systems have this deadline as a KPI. However, we are now in a time where clinicians are overwhelmed with treating patients on the frontline. They do not have the capacity to be involved in root cause analysis. Multi-disciplinary meetings need to take place – clinicians do not have the time to schedule these meetings as they are working flat out.

    Thankfully, this has been recognised by our local Clinical Commissioning Group (CCG). They have given us a grace period, we are no longer bound by the 60 day rule.

    This will now lead us into a backlog of investigatory work. It leaves me with so many questions:

    • How can an investigation take place weeks or months after the event?
    • Relatives and patients deserve answers – how do we manage their expectations?
    • We are always firefighting – what proactive measures are being used/developed to manage waiting lists?
    • Will every death on the waiting list need to be investigated as the root cause will be the same… COVID pressure/lack of capacity?
    • If patients are ‘lost’ or died – currently we have no way of knowing – this is not acceptable. Is there a better system?

    Patients waiting to be referred into the hospital

    The above patients are patients we have inside the hospital system. What about patients waiting to be referred into the hospital? This opens up yet another huge number of patients waiting to see a hospital specialist. For example, you go to your GP with vision disturbances. They then refer you to the ophthalmologist at your local hospital – or if it is an unusual presentation, you may be referred to a specialist centre. The amount of patients being referred into their local hospitals are increasing on a daily basis. This list is not decreasing. This will lead to increased harm to patients suffered from delays.

    This ever increasing list of patients is currently not being managed, not being monitored or triaged. Where I work there are over 5000 people on this list.

    It is a ticking time bomb. A latent consequence of this awful pandemic.

    NHS England, please help

    NHS England – please give us guidance in how we can manage this. The wave of latent harm is on the horizon for hundreds of thousands of patients.

    • Patients need to know what to expect and what their rights are.
    • We needs guidance on the management of waiting lists in hospital.
    • We need guidance on managing waiting lists to see a specialist from primary care.
    • We need guidance on managing these potential, historical investigations.

    The NHS is already drowning. If patients are harmed or have died as a result of long waits and not investigated, expect litigation. We need open and honest discussion about this. The time to act is now.

    About the Author

    Jerome is a patient safety manager in an acute NHS Trust in the North of England.

    3 reactions so far

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    Good to see the issue of referrals getting lost mentioned. This is usually a 'systems problem', and it needs attention. Nobody wants this to happen.

    I recommend that #patients are encouraged and helped to be part of the referral process. Doing this prevented a friend's urgent referral for cardio-version / cardiac ablation being missed. Had he not chased up the referral himself, and been persistent, he would not have been treated. The referral had not got through to the relevant team. We never did find out what had happened to it.

    I recommend all patients (who can) keep copies of all letters / summaries / consultations /test results and referrals, and follow this up themselves if there is a delay.



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