Why doctors do not answer referral letters

Abstract

BACKGROUND: Health care workers at primary health care (PHC) clinics are frustrated by not receiving replies to their referral letters to doctors. Referral letters act as permission slips to allow patients easy access to treatment by specialists at secondary and tertiary service levels. Reply to the referral letter is vital for continuity of care to be maintained and to enable comprehensive recording at PHC level. It has been found that poor feedback leads to poor follow-up care in the PHC setting. Previous research has investigated the influence of the method of communication, either by use of pro forma letters or by electronic feedback on answers. The study, on which this article is based, endeavoured to understand the doctors' reasons for not replying to referral letters and the context contributing to this problem. If this matter could be resolved it would relieve frustration at PHC level and improve health care services in future. METHODS: A qualitative study method was used, as the purpose of this study was to understand and explore in depth doctors' context, perceptions and motivation leading to not answering referral letters. In-depth interviews were conducted with six purposefully selected doctors who all had more than one year’s experience in their different departments. The exploratory question posed was: "What factors are contributing to not replying to referrals from primary health care clinics?" Interviews were tape-recorded and transcribed verbatim. Themes were identified by using the Tesch method. Analysis was done independently by two coders, who afterwards reached consensus on themes identified. After analysis of each interview trustworthiness was further ensured by going back to the participants to verify that the interpretation represents an accurate description of the participant’s view. RESULTS: The participants included one consultant and five registrars with between 18 months and 8 years experience in their departments respectively. According to participants, many reasons contributed to not writing answers to referral. The reasons for not replying to referral letters pertained to the working situation at the referral hospital and factors regarding the referrals themselves on the one hand and the hospital doctor's perceptions as to his/ her role in the health care system and his/her perception that it is futile to answer referrals on the other. CONCLUSION: There were multiple reasons for not replying to referral letters. It has been suggested in this article that the referring personnel can address some of these reasons by ensuring accurate referrals on appropriate days, considering style preferences of the hospital doctors and by the use of pro forma letters. Hospital consultants can address other factors by giving attention to the socialisation of their juniors and by management by adjusting the referral system so that it does not rely on patients to courier letters. Further research needs to be undertaken in South Africa to assess the influence of various methods of communication in the referral system as regards the quality of communication between different levels of care.