How to the health system can work for you

The healthcare system in South Africa operates in a hierarchical structure. Community-based services are at the base of the pyramid and central hospitals are at the apex.

A functional referral system is essential for the effective operation of such a health system. Referral refers to the processes by which professionals and institutions communicate and collaborate to protect, promote, and restore an individual’s health.

This referral policy and implementation guidelines ensure a close relationship between all levels of the health system. It should assist in making cost-effective use of hospital and primary care services.

Moving a patient to another level of care could be internal, upward, downward, or lateral for continuity of care.

For a referral system to work at its best, all levels of the healthcare delivery system need to function optimally.

Each facility needs to be clear about its role, responsibilities and limitations; have protocols of care for conditions specific to that level of service readily available; and have suitable means of communication and transport to access support from other levels of care.

The specific objectives of the policy are to:
• Ensure that clients receive optimal care at the appropriate level.

• Strengthen coordination and complementation between levels of care, units and institutions in caring for clients.

• Facilitate optimal and cost-effective use of high-specialist facilities within and across provincial borders.

• Strengthen peripheral health facilities through feedback that will enhance the skills of the referring doctors by confirming or not confirming diagnoses.

• Enhance the utilisation of services at the primary health care (PHC) level by those in need of care.

• Progressively reduce unnecessary burdens on tertiary and specialist hospitals.

• Define governance and other arrangements for referrals between public and private sectors.

Structure and organisation of the referral network:
The referral network links the different levels of care based on the expected services in the defined package of services.

The levels of care include all facilities – community-based services (ward-based PHC outreach teams, integrated school health teams, traditional health practitioners and home-based care organisations); facility-based PHC services; community healthcare centres; specialised hospitals (multi-drug resistant-TB and mental health); district hospitals; regional hospitals; tertiary hospitals; central hospitals; private general practitioners; private specialists and private hospitals; and EMS.

Primary healthcare clinic:
A primary healthcare clinic is the first step in the provision of health care. It offers services such as immunisation, family planning, anti-natal care, treatment of common diseases, the treatment and management of tuberculosis, HIV/Aids and counselling. If the clinic cannot assist, they will refer the patient to a community health centre.

Community healthcare centre:
A community healthcare centre is the second step in the provision of health care but can also be first-contact care. Community healthcare offers similar services to a primary healthcare clinic.

It has the addition of a 24-hour maternity service, emergency care and casualty and a short-stay ward. The community healthcare centre will refer a patient to a district hospital when necessary.

District hospital:
This is the third step in the provision of healthcare. These hospitals will receive referrals from and provide generalist support to community health centres and clinics such as diagnostic, treatment, care, counselling and rehabilitation services.

Clinical services include surgery, obstetrics and gynaecology, out-patients, medicine, paediatrics, mental health, geriatrics, casualty and clinical forensic medical services.

These hospitals receive referrals from the community health centres and clinics. Doctors and primary health care nurses will deliver the most care.

If the district hospital cannot help a patient, they will refer them to the local regional hospital for treatment.

Once the patient’s healthcare needs have been met, the patient should be referred to the lowest level of care within the community as appropriate for continued support.

Referral categories:
• Emergency referral: an emergency necessitates the immediate transfer of clinical responsibility to the most appropriate health establishment.

• Non-urgent referral: a consultation with a medical specialist, medical practitioner, nurse or other relevant primary health providers (physiotherapist or health promoter) as the patient’s condition would be better managed through additional support.

The receiving healthcare provider specialist will not automatically assume clinical responsibility for ongoing care, as the responsibility will vary with the clinical situation.

• Transfer: the clinical responsibility for the patient’s management is transferred to the most appropriate practitioner as warranted by the patient’s condition.

• Down referral: healthcare providers at higher levels of care, after managing the clinical condition of the referred patients, may refer the patient back to the original referring facility at a lower level of care or to the community-oriented services for continued management, rehabilitation or palliative care.

Responsibilities of the client:
• The client should access the health service at the lowest level of care closest to their home.

• In the event of a referral, the client or next of kin should provide consent for the referral. Clients or next of kin who refuse consent for a referral or transfer should sign a form indicating they are against medical advice.

• After the transfer back to the initiating facility, the client should provide the healthcare worker at the initiating facility with all the documents provided by the receiving facility.

• Patients should respect the transport protocols of EMS in terms of departing times and alighting points.

Republic of South African Department of Health; Referral Policy for South African Health Services and Referral Guidelines, August 2020

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