Referring wisely? or referring when you need help?

Editor – The Royal College of Physicians (RCP) has produced a report on inpatient referrals from generalist to specialist teams describing the presentations and conditions specialists feel ought to be referred, and conversely those which do not require this.¹ Inpatient referral is a neglected area and this report is to be welcomed in so far as it intends to start a conversation about the role of this activity.

Referrals within a hospital are a source of interpersonal conflict and can be met with an aggressive and obstructive response.² One reason for this is that meeting inpatient referral demand is low on department priorities. It is a largely unrecorded and often poorly resourced activity. If a clinician in the NHS spends the afternoon seeing five new patients in clinic this will generate >£1000 of department income, but seeing five new ward referrals is unlikely to generate any income.

It is regrettable that this survey was confined to being a supply-side enquiry, only asking the specialist providers of referrals for their view. Specialists are motivated to restrict their referral work to interesting and complex presentations but a generalist may require their help or advice on more prosaic matters. Whether or not a phone call for advice constitutes an ‘inappropriate referral’ depends very much on where you are sitting, rather than on the content of the question.

We don’t yet know the end-point of the conversation that this report intends to start but it is at least possible that it will end with referral rationing. With that in mind it is premature for the authors to state that ‘referring wisely benefits physicians and patients’ as they commented in their associated statement (www.rcplondon.ac.uk/news/patients-and-physicians-benefit-referring-wisely). This assertion conflates the title of the report with the underlying activity. The RCP should avoid a descent into propaganda, even if the rest of the world is using newspeak.