The referral backlog: Patients, doctors and HSE may suffer without action

Dr Rob Hendry, Medical Director at the Medical Protection Society (MPS), outlines the steps necessary to better protect patients and doctors in the altered healthcare landscape brought about by Covid-19

The need to reduce the number of patients attending healthcare facilities and the suspension of routine investigations and outpatient appointments has resulted in a large backlog of referrals across many specialties and in many centres.

The IMO warning to the special Oireachtas committee on Covid-19 in early June was stark and highlighted the scale of the challenge ahead: 570,000 people are waiting for an outpatient appointment and a further 230,000 are on a waiting list for an inpatient or day-case procedure.

GP access to diagnostics and referral pathways have effectively been closed down, and while patients already within the four national screening programmes (BreastCheck, CervicalCheck, BowelScreen and Diabetic RetinaScreen) continued to be treated during the Covid-19 crisis, new referrals will have quickly built-up.

According to HSE figures, more than 2,700 patients were waiting for an urgent colonoscopy at the end of May. Almost half of them were waiting longer than the 28-day target.

While screening services are resuming or are planned to resume, it will take some time for all services to be up-and-running normally and, of course, it is not only cancer referrals that have been affected.

Here, as in many countries, we must review which patients will be granted priority. But what does that mean for others who may be left behind?
If diagnoses are missed or significantly delayed, this could seriously impact those patients’ prognoses and outcomes. It is not difficult to see how we could be facing another different kind of patient safety crisis.

Adverse outcomes

The prospect of an adverse outcome under these circumstances would be devastating for any patient, who would not know whether outcomes would have been different were it not for the pandemic or agonising over which link in the diagnostic chain could have turned things around. The psychological impact on the already emotionally and physically exhausted doctors involved would also be significant.

Such situations may also give rise to medico-legal disputes, claims and investigations — indeed, nearly two-in-five doctors (38 per cent) tell us they are concerned that they will face a regulatory or criminal investigation if patients come to harm as a result of delayed referrals or non-Covid-19 services being unavailable or limited. This does not seem right.

We are calling on the Government to introduce temporary emergency laws to protect doctors from investigations arising from impossible situations like this. In the US, 34 states have introduced some form of civil liability protection for physicians providing care in the pandemic.

In a recent survey of the public, commissioned by the MPS, seven-in-10 people (70 per cent) say they too would support emergency laws. The public has shown great support for HSE frontline workers and it appears this support extends further — to doctors being better protected following their efforts during the crisis.

We also hope the Medical Council will offer greater reassurances for doctors. It has committed to taking the specific facts of each case into account, and this is welcome, but we feel it could go further by issuing a statement to the effect that doctors will not be subjected to any regulatory action following decisions made in good faith during the crisis.

Best practice

In the meantime, the referral backlog must be dealt with expeditiously.
The sharing of best practice and lessons learned will help significantly. For example, we know some centres have dealt with the disruption to the usual referral pathways by adapting how they deal with them. Improved dialogue between primary and secondary care physicians has not only helped them to assess which patients need urgent investigation, but is also improving inter-physician dialogue.

Anecdotally, a number of doctors have told us that they find this renewed, more personal relationship to be refreshing and rewarding, and some are even considering adopting their modified, more efficient approaches to managing patient investigations when the pandemic has truly receded.
Some other units started planning some time ago on how they will cope with routine investigations, such as endoscopy, by rearranging rotas in order to start lists earlier and work later; and dealing with the backlog as quickly as possible so it does not become, or feel, insurmountable.

During the height of the Covid-19 crisis in Ireland, the healthcare community demonstrated how the system can move quickly by implementing creative ways of working and new ways of using technology.
While many healthcare workers will be exhausted, this same drive will be needed to tackle the referrals backlog. With this — alongside Government-led planning, support and resources — it is just possible that the looming secondary patient crisis could be averted.

MPS stands ready to assist and we continue to do everything we can to support our members through these challenging times.