Referral steps in district health system are side-stepped

Abstract

To the Editor: The South African public health sector follows a hierarchical referral system. District hospitals play a central role between the primary health care (PHC) clinics, community health centres (CHCs), regional and tertiary hospitals. They provide level one (generalist) services to in- and outpatients referred from PHC clinics and CHCs. District hospitals should ensure that patients are treated at the appropriate level of care and receive continuity of care. 1 However, patients often go directly to district hospitals, resulting in increased caseloads. Studies have identified several factors (e.g. accessibility, acceptability, efficiency and effectiveness) that might influence a referral system and its usage. 2-4 We aimed to develop an understanding of the South African district referral system. Methodscross-sectional study design was applied at the Dr J S Moroka Hospital, the only district hospital in the Thaba Nchu health subdistrict, Free State, and a referral point for 11 clinics in the sub-district, 4 clinics from the neighbouring sub-district, and 5 GPs’ rooms. Routinely collected information on patients’ records and registers was reviewed. The study was approved by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand. Resultsof 528 patients were registered during the study period; 241 (46%) were registered in the out-patient department (OPD) and 287 (54%) in the casualty department. Categorising these patients suggested that 68% in OPD and 38% in casualty units would require hospital care; the rest could be seen at the PHC facilities (clinic and CHC). One hundred and twelve patients (39%) in casualty were seen during weekends. More than 50% of patients in both units were self-referrals. Ambulances took 31% of the patients directly to the hospital’s casualty department, bypassing the nearest PHC facilities. Although 66% of chronic cases were seen in OPD, a third of them came to casualty; 28% of patients seen after-hours at casualty were chronic cases. In both designated areas, most patients were treated and discharged on the same day. As expected, most patients (68) (25%) were admitted from casualty rather than OPD (18) (10%). Most acute cases (75%) were seen at casualty; of these, 60% were self-referred, whereas most (82) (61%) chronic patients were referred. The proportion of self-referred patients was similar (52%) during working hours and after hours. During weekends, 56% of patients were self-referrals, as 9 out of 11 clinics do not operate after hours. In the OPD, the most common presenting problems were circulatory system related (35) (17%) followed by infectious and parasitic diseases (24) (12%), injury and poisoning (23) (11%) and respiratory diseases (18) (9%). In casualty, most patients were diagnosed with injury and poisoning (76) (28%), respiratory diseases (46) (17%), circulatory system diseases (26) (10%) and diseases of the digestive system (31) (11%). Commonly cited reasons for self-referral were desire to be seen by doctors (47%) and perceived poor services at clinics (32%). The average estimated distance travelled by patients to their nearest clinic was 11 km (range 3 - 40 km); viz. the 24 km to this hospital (range 14 - 56 km). Discussionpatients seen in OPD and casualty had bypassed the referral