• I L Haeusler, M Sajan, and A Parrish.
• Thames Valley and Wessex Leadership Academy, National Health Service, UK; Institute of Child Health, University College London, UK. ilsa.haeusler@gmail.com.
• S. Afr. Med. J. 2020 Apr 29; 110 (5): 396-399.

BackgroundSome patients need referral within the health system to achieve optimal care, and referral letters are an important part of this process. Healthcare practitioners often complain that referral letters lack information, are inaccurate, or direct patients to the wrong place. Poor communication affects patient experience and outcomes, has budgetary and service planning implications, and impacts on staff relationships and morale.ObjectivesTo investigate the quality and appropriateness of referral letters received by the medical outpatient department of a regional hospital in Eastern Cape Province, South Africa.MethodsLetters were collected by departmental staff as patients arrived at the clinic. Each letter was independently analysed by two healthcare workers for content and appropriateness, using defined criteria.ResultsOf 100 letters collected between March and May 2017, 85 were suitable for analysis. Patient and clinician identifiers were present in >85%, but key clinical information was missing in 87%, and 48% did not state a reason for referral. It was possible to make triage decisions based on the letter in only 35% of cases. Nineteen percent of referrals were classified as inappropriate.ConclusionsMost letters lacked important clinical information, probably because of a combination of factors: gaps in clinical knowledge of referring clinicians who service a population with a high burden of disease and complex pathology; under-resourced peripheral healthcare clinics; inadequate staff-to-patient ratios; and time constraints. A suggested focus for improvement is education at undergraduate and postgraduate level, which should emphasise preparation for community service, specifically highlighting techniques for preparing good-quality referrals.

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