Psychiatric Bulletin (2006) 30: 452-453. doi: 10.1192/pb.30.12.452
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 452-453
© 2006 The Royal College of Psychiatrists
Quality of referrals to old age psychiatry following introduction of the single assessment process
Kathleen Ferriter, Associate Specialist,
Partha Gangopadhyay, Senior House Officer,
Ramin Nilforooshan, Senior House Officer and
Mark Ardern, Consultant Psychiatrist
Central North West London Mental Health Trust
James Warner, Senior Lecturer in Old Age Psychiatry
Claybrook Centre, Charing Cross Campus, Imperial College, St
Dunstan’s Road, London W6 8RP, email:
j.warner{at}imperial.ac.uk
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
We sought to identify changes in the quality of information in referrals to
an old age psychiatry service before and after the introduction of the single
assessment process. Referrals were compared in terms of length, legibility,
information and clinical utility.
RESULTS
Compared with letters before the introduction of the single assessment
process, referrals made on the new forms took longer to read (mean 96
v. 124 s, P=0.001), had more illegible sections
(P=0.011), contained less information (P=0.026) and were
judged to be less clinically useful (P=0.001).
CLINICAL IMPLICATIONS
The introduction of the single assessment process has impaired clinical
communication between general practitioners and psychiatrists, and might be
prejudicial to patient care.
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Introduction
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The single assessment process, a key element of the National Service
Framework for Older People, was introduced to facilitate referrals between
agencies and reduce duplication for patients, carers and clinicians
(Department of Health, 2001;
Swift, 2002). All referrals
between agencies are now expected to be made on designated forms. Although
there is no uniform national pro forma, many localities, including our own,
undertook rigorous consultation and development of referral forms, the use of
which became mandatory for referrals to our service in April 2004. The
referral form consists of several free-text sections: identity of patient and
carer, identity of referrer; reason for referral; assessment of urgency; risk
factors; current services provided to patient; diagnosis and recent history;
current medication; signature of referrer. Following the introduction of the
single assessment process, we noticed a deterioration in the quality of the
referral information. Our aim was to conduct an audit of referrals from
general practitioners before and after the introduction of the single
assessment process.
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Method
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We identified 20 consecutive new referrals from primary care to an old age
psychiatry service in North West London for the year before the new form was
introduced (April 2003 to March 2004 - from 15 different general practices)
and the following year (17 practices). All referrals were anonymised and all
dates and identifiers were removed.
Legibility and length
A timed reading of each referral was undertaken by one clinician who was
unaware of the aims of the survey. The word count and number of illegible
passages were noted.
Content
Each referral was transcribed into unformatted text (to facilitate masking)
and was rated by an independent clinician for content as suggested by Roland
& Coulter (1992). The
domains of information assessed were: presenting problem; reason for referral;
history of presenting problem; findings on examination; current treatment;
allergies; previous treatments; past medical history; social circumstances;
investigations; expectation of follow-up; urgency of referral. Given the
nature of referrals to psychiatric services we included assessment of risk as
an additional domain (details of risk assessment are requested on the referral
form). Where the rater judged that any (even incomplete) information was
provided in any domain, that domain was scored as present.
Clinical utility
Two senior clinicians performed independent and masked rating of each
referral, using a 5-point Likert scale of ‘strongly agree’ (1) to
‘strongly disagree’ (5). The raters answered the questions
‘I am able to judge the appropriateness of the referral’, ‘I
would need to seek further information before processing this referral’
and ‘Overall I think this referral is useful’. Data were
dichotomised to allow kappa (interrater) estimations.
Data analysis
Data were analysed using 
2 and Mann–Whitney tests as
appropriate with the Statistical Package for the Social Sciences version 11
for Windows.
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Results
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Results are shown in Table
1. In all areas assessed, the quality of the referral information
was significantly worse after the introduction of the single assessment
process. Interrater agreement (kappa) of clinical utility between the two
masked raters was 0.85, 0.78 and 0.86 respectively for the three questions
detailed above.
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Table 1. Content and utility of referrals to an old age psychiatry service before
and after the introduction of the single assessment process
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Discussion
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This survey found a significant reduction in the quality of referral
information after the introduction of the single assessment process, despite
considerable prior planning and promulgation in our area. There are a number
of reasons that might explain this: the length and inflexibility of the form
may deter clinicians from adequately completing it; some general practitioners
who previously dictated referral letters now hand-write the forms, which may
be more time-consuming; the inflexibility of the forms may stifle creative
thinking (which we believe to be an important component of good writing).
Conversely, structured referral forms may help to focus the referrer on the
significant issues and avoid the omission of important information. We found
no evidence to support the latter and our findings suggest that clinical care
may be compromised because important information is omitted from referrals
made on the new referral form. We hope that the quality of referrals will
increase over time, as referrers get used to the new format. In the interim,
we believe that clinicians receiving poor-quality information should always
contact the referrer before processing the referral.
Before and after surveys may be criticised because confounders, for example
changes in staff and new policies or contracts, may account for the
differences found. Although we cannot exclude such interactions, at a time of
expansion and improvement in the health service we believe that the
deterioration found is contrary to expectations. One further potential
limitation was that, despite attempts at masking, raters may well have been
aware of the status of the referral when judging clinical utility. One of the
aims of the single assessment process is to improve communication across all
disciplines. Our study only focused on communication from general
practitioners because we felt this group had been most affected by the
changes. Interestingly, few new referrals from social services and other
agencies are made on designated forms.
Although various professions have expressed reservations about the single
assessment process (Cohen,
2003; Glasby,
2004), we are unaware of any critical evaluation before or since
its introduction. Attractive but heuristic policies are often accepted
uncritically because they are difficult to assess using randomised controlled
methods. We believe that the single assessment process requires further
evaluation. In future, more care should be taken to assess fundamental health
policy changes before they are introduced.
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References
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COHEN, Z. A. (2003) The single assessment process: an
opportunity for collaboration or a threat to the profession of occupational
therapy? British Journal of Occupational Therapy,
66, 201
–208.DEPARTMENT OF HEALTH (2001) National
Service Framework for Older People. London: Department of
Health.
GLASBY, J. (2004) Social services and the single
assessment process: early warning signs? Journal of
Interprofessional Care, 18, 129
–136.[Medline]
ROLAND, M. & COULTER, A. (1992)
Hospital Referrals. Oxford: Oxford University
Press.
SWIFT, C. G. (2002) The NHS English National Service
Framework for Older People: opportunities and risks. Clinical
Medicine, 2, 139
–143.[Medline]
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Abstract
Introduction
