The key to improving the quality of GP referrals

Ian Rubenstein, RCGP Clinical Lead for Two Week Wait Forms

I'm a busy GP who has to complete many different referral forms.

Forms have varying layouts and are often poorly designed, with no thought having been given to general practice workflow principles. They also change with alarming frequency, often just to accommodate new trust logos. Keeping track of changes to forms wastes clinical and administrative time - it’s a poor use of human resources within a hard-pressed health service.

And it's getting worse…

CCG community-based clinics have strict referral criteria, so more forms are fluttering onto our desks like confetti at a wedding. However, this is a marriage made in hell, and failure to get forms right can be disastrous.

In April 2014, London Cancer North East released a set of two week referral forms with multiple formatting problems. They caused referral delays and ultimately had to be withdrawn, causing confusion for both GPs and hospital trusts.

Funded by the College, the Sowerby Fund and Cancer Research UK,  I worked with London Cancer North East's Transforming Cancer Services Team to develop better two week referral forms based on my concept of a standard NHS GP referral form layout. They have been tested for usability using principles borrowed from the field of software development. My philosophy is that forms are software, not paper, and software should always be tested.

The forms work with the three major GP computer systems and were released in early 2015. London Cancer North East is now in a very different position; positive feedback from GPs and trusts regarding the new forms encouraged the larger organisation, London Cancer Alliance, to join forces with London Cancer North East. I am now helping to develop London-wide two week referral forms based on my standard referral form layout, which will incorporate the latest NICE guidelines.

Our experience of developing and testing a new set of two week referral forms can be used as a case study for implementing successful quality improvement in the NHS. Borrowing principles from the software development industry, any changes made to forms  were thoroughly checked for usability before being released to GPs for field testing. We then incorporated user feedback, adjusted the forms and put them out to test again. We repeated this cycle many times before releasing the forms for wider use.

When we finally released them, we did so in a series of carefully-planned stages, making sure they were properly tested beforehand. We also made sure we were in a position to monitor and respond to any unforeseen problems.

Standardised forms, tested for usability, offer higher quality and more consistent information to the departments which receive the completed forms. Everyone benefits: GPs, specialists and patients. If the forms can be shown to improve referrals for suspected cancer, they could then be adapted as templates for any type of GP referral throughout the entire NHS.

They would be like blank keys, ready to be cut for any lock. GP NHS gatekeepers would finally have a bunch of shiny new keys.

For more information on Two Week Wait forms, please visit the London Cancer website.


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