Referral steps in district health system are side-stepped.

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. Methods A cross-sectional study design was applied at the Dr J S Moroka Hospital, the only district hospital in the Thaba Nchu health sub-district, 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. Results A total of 528 patients were registered during the study period; 241 (46%) were registered in the outpatient 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 …