Pitfalls and potential dangers in the referral process to a specialist brain injury unit

AIMS AND METHODS 

We looked retrospectively at referrals over 1 year and determined the length of time from receipt of the referral to the date when authorisation to see the patient was given, and the time from authorisation to first contact. For in-patients we determined the time from the recommendation for admission to the time authorisation was granted, and the time from authorisation to admission.

RESULTS 

Of the 108 referrals, 80 (74%) were seen within 13 weeks (mean=53 days); 7 patients (6%) had to wait over 13 weeks, usually because of delays in authorisation; 10 patients were admitted; 14 were never admitted (although we had recommended admission). The time from recommendation to admit to authorisation of admission, 27 days, was the same as the time they waited for a bed once authorisation had been given.

CLINICAL IMPLICATIONS 

Waiting for authorisation seemed in some patients to delay their access to tertiary services. Any advantage of using panels to authorise referrals, like ensuring better use of local resources, may be outweighed by patients taking longer to get the care that best meets their needs.

Pitfalls and potential dangers in the referral process to a specialist brain injury unit

AIMS AND METHODS
We looked retrospectively at referrals over 1 year and determined the length of time from receipt of the referral to the date when authorisation to see the patient was given, and the time from authorisation to first contact. For in-patients we determined the time from the recommendation for admission to the time authorisation was granted, and the time from authorisation to admission.

RESULTS
Of the 108 referrals, 80 (74%) were seen within 13 weeks (mean=53 days); 7 patients (6%) had to wait over 13 weeks, usually because of delays in authorisation;10 patients were admitted;14 were never admitted (although we had recommended admission). The time from recommendation to admit to authorisation of admission, 27 days, was the same as the time they waited for a bed once authorisation had been given.

CLINICAL IMPLICATIONS
Waiting for authorisation seemed in some patients to delay their access to tertiary services. Any advantage of using panels to authorise referrals, like ensuring better use of local resources, may be outweighed by patients taking longer to get the care that best meets their needs.
The Lishman Brain Injury Unit has expertise in the diagnosis and management of adults with cognitive, behavioural and psychiatric sequelae of acquired brain injury. There is an out-patient service and a small in-patient unit for the medically and surgically stable. Patients may have acquired their injuries in a variety of ways, often after road traffic accidents or hypoxic brain injury.
The unit acts at a tertiary level with the majority of referrals coming from consultants in district general hospitals and mental health professionals. When a referral is received a decision is made as to what further action is required. This may take the form of an out-patient assessment. If an outreach assessment is needed a member of the team will assess the patient, usually with a view to determining their suitability for in-patient admission to the unit.
Those who commission the service need to be confident that what is being recommended by the specialist unit is appropriate. Over the last few years more and more authorisation panels have been set up by local primary care trusts to oversee specialist referrals. In some cases these panels seem to have led to additional delay for the patient before they can be seen. It is important to understand any delays in the system, partly because of the National Health Service's (NHS) target for all patients to be seen within 13 weeks of referral (Department of Health, 2000).
The aim of the present audit was to investigate the influence of any delay getting authorisation for funding on the overall waiting time from receipt of referral to the first out-patient appointment or date of admission.

Method
We reviewed referrals to the service between 23 are different to those for authorisation of in-patient admissions. For outreach and out-patient assessments, when a new referral is received, the unit administrator immediately seeks authorisation. Authorisation is usually based on certain criteria being met (e.g. that the referrer is a consultant) and does not usually require any commissioning panel to endorse the referral. Once authorisation is confirmed, the patient is then either offered an appointment to be seen in the out-patient clinic or an outreach appointment is arranged. Most of those who are in-patients in other hospitals at the time of referral are seen as outreach assessments. The two time intervals of interest are therefore: 1. The time between receipt of referral and the date at which authorisation to see the individual is given. 2. The time between authorisation and first planned (outpatient or outreach) contact with the patient.
For in-patient referrals a further level of authorisation is required. If following an out-patient, or more commonly an outreach assessment, the team recommends that the patient would benefit from in-patient admission, authorisation for admission is sought. This usually requires negotiation with a tertiary referral panel. Once authorisation is given the individual is placed on the waiting list. The two time intervals of interest are: 1. The time from our recommendation that the person is suitable for in-patient admission (i.e. the date we seek authorisation) to the date authorisation is given. 2. The time between authorisation and admission to the unit.
As well as establishing the time intervals above, the audit attempted to find reasons for any delays that were identified. Those waiting longer than the 13-week period specified for out-patient appointments in the NHS Plan (Department of Health, 2000) were highlighted. Data were also collected on the referrer specialty and the authorising primary care trust.

Results
A total of 108 individuals were referred in the period audited. A large number of primary care trusts only referred one or two people each, with a few each making quite a few referrals (Fig. 1); the trusts with high rates of referral tended to be within Greater London, and therefore nearer the unit (Fleminger et al, 2006). The mean time from receipt of the referral to authorisation (8 days) was considerably shorter than the mean time from authorisation to first planned contact (45 days) ( Table 1). The vast majority of individuals were seen within 13 weeks. We looked in more detail at the 7 people who breached the 13-week target and found that the reasons were primarily related to delays in obtaining authorisation. Where no contact was planned this was owing to a variety of reasons, including referral onto other more suitable services and referrers cancelling the request.
We recommended admission for 25 individuals ( Table 2); 10 were eventually admitted and the average time taken to get authorisation was almost 4 weeks, the same as the average time between authorisation and a bed being available. For 8 the admission was not authorised. The mean waiting time for these individuals from referral to the decision not to authorise was 74 days; 6 people were authorised but subsequently did not need admission, and 1 person was still awaiting admission at the time of data collection.

Discussion
Out-patient referrals were generally processed in an efficient manner and delays were very much the exception. However, delays in authorisation did seem to contribute to the few patients who had to wait over 13 weeks before they could be seen.
For in-patient admissions, delay at the authorisation stage was a significant factor and effectively doubled the time the patient had to wait to be admitted. This delay, while the authorisation is obtained to admit the patients, is unsurprising because in the majority of cases it relies on an authorisation panel. Given that these panels rarely meet more frequently than once a month, such a system inevitably leads to delays in accessing appropriate treatment. The delay is often compounded while the panel awaits additional clinical information. In addition, because an additional level of bureaucracy is interjected into the referral to admission pathway, this often causes delays elsewhere in the system, as the referring team have to be notified of the authorisation process and complete the necessary paperwork.
Most of the patients we admit come from acute medical and surgical wards. By the time we recommend admission to our unit they are usually medically and surgically stable. Therefore when the patient waits to be admitted they are blocking an acute medical or surgical bed; others are being denied timely access to treatment. For the referred patients themselves, the environment of an acute medical or surgical ward is not appropriate and may result in unnecessary antipsychotic medication being used (Fleminger, 2003). Access to rehabilitation services may also be delayed, and therefore result in worse treatment outcomes (Cope & Hall, 1982).
The audit also demonstrated the considerable delay for some patients before a final decision is made whether or not to authorise the admission. This results in uncertainty for the referrer, patient and their family. Given that the brain injury itself will have been a very distressing and psychologically traumatic event surrounded by uncertainty about prognosis, any additional uncertainty about accessing the most appropriate treatment is likely to be, at best, frustrating and at worst deeply demoralising. Furthermore, our impression is that if anything, the situation has got worse since these data were collected, both in terms of in-patient and out-patient referrals, with regard to the time that it takes for referrals to get authorised.
The answer probably lies in clearer referral pathways and better links between clinicians who make the referrals and their primary care trust commissioners who need to authorise them.