REFERAL SYSTEM

In working, discussing or understanding South African health care it is important to understand the referral system. Like most other referral systems, i.e. HMO’s, a patient must go to his primary care doctor and get a referral to a more specialized doctor for any complication or procedure his/her primary care doctor cannot perform.

As we’ve explained to some of you, a patient who needs an ICD (chest tube) is required to go to a local day hospital/community care center (aka his primary care doctor). The day hospital can place the ICD but they do no further ICD treatment. The patient is then referred up to the local secondary hospital, like Jooste. On referrals a patient is transported between referrals via ambulance and ‘porters’. (That is good news; we had thought it was the patient’s own responsibility to get from referral to referral.)

Patients transferred to Jooste are admitted into the casualty (ER) from the day hospital. The casualty doctor’s evaluate them and once the patient is stable the transport them to the ICD ward at Magnolia hospital. The ICD has physical therapist there to assist in breathing exercises and rehabilitation. After the patient is ready for discharge, they are transported back to Jooste for discharge where the ICD is removed, the site is sutured and the patient leaves. From our research, it appears most patients only stay about 3 days.

The general consensus of the referral system is that it’s a bit frustrating and better in theory. The theory is that when there are such few resources, they must be maximized as greatly as possible. So day hospitals are pretty common and have only the basic care resources. Moving up the referral system chain, the next level health care facility will have a bit more resources to treat a few more complications. And ultimately the highest-level health care facility in the referral system has the most advanced technology for the area. This way the Department of Health does not have to have machines at every hospital, only at the perspective secondary, tertiary, etc.  (For instance there are only 3 modern ultrasound machines in the Western Cape region and they are all at the higher referral hospitals). The referral system follows South Africa’s general sense of hope, as it was said to me. It’s a system based on hope that there are no complicated patients. That a patient with a cold can simply go to the day hospital for treatment. And that the cold is not in fact a complication from ARV’s and a sign of system failure that would require more advanced treatment than that available at a day hospital.

We can all understand the frustration with referral systems with our own understanding of the HMO system. Now just think about this in an emergency situation, when you can’t wait 2 weeks for a new appointment. In the states a patient would arrive at the ER and be rushed to surgery if needed. In this referral system a patient must go to the day hospital first, then get referrals to more advanced treatment. Of course if a patient arrives at Jooste without a referral letter from a day hospital he/she will still be treated. In that regard I don’t quite understand the consequences a patient would face if he/she just arrived at the highest-level care requesting treatment.