Health systems are responsible for improving people’s health and protecting them against the financial costs of illness while respecting their dignity and status. In recent decades, the health systems of developing countries have put extensive reform programs on their agenda to meet the growing needs of patients. One of these reforms is the implementation of the referral system (Akbari-Sari et al., 2022). According to the definition of the World Health Organization (WHO), a referral is a process in which a healthcare provider at a level of the health system, because of lacking enough resources (medicine, equipment, skills) to manage the patient’s clinical condition, looks for a center at the same or higher level which has sufficient resources to provide better services to address the patient’s condition (Seyed-Nezhad et al., 2022).
The right referral system can greatly reduce the burden of specialized and sub-specialized referrals to hospitals. The importance of the referral system is because 55% of patients with non-emergency health problems who are referred to emergency centers could be cared for by a general practitioner or with the advice of lower-level staff. Meanwhile, a study conducted in the northern provinces of Iran showed that the referral system was unfavorable in 67% of cases (Tavakoli et al., 2017). Although the goal of health system improvement is to provide access to health services for all individuals, there is not enough evidence that there is a sufficient specialized workforce in this regard. The shortage of doctors per patient is a problem in many regions, including developing countries. For instance, in India, the doctor-to-patient ratio is estimated at 1.34 doctors per 1000 people (Nanda & Anilkumar, 2021). Studies in Iran also confirm the shortage of general practitioners for the population (Ahmadifard et al., 2022). As the demand for health services increases, effective use of the workforce is critical to ensure the delivery of high-quality and cost-effective health services. The annual growth rate of the nursing workforce worldwide is 3 to 9 compared to that of physicians. This has caused some countries to use the potential of specialist nurses instead of doctors in comprehensive health service centers to increase productivity, provide health service coverage for all, and reduce costs (Nanda & Anilkumar, 2021). Review studies conducted in the US, Russia, and South Africa confirm major findings in terms of greater patient satisfaction and also reduction in hospital admissions and patient mortality with care led by nurses compared to physicians. Similarly, other developed countries report no significant differences in referrals, prescriptions, tests, and investigations ordered compared to physician-led care. Studies conducted in the Netherlands and the United Kingdom also demonstrate lower costs of health services compared to the physician model (Maier et al., 2017). Evidence shows that nurses provide more consultative information to patients than physicians, spend more time with patients, and provide comprehensive care that results in greater patient satisfaction. Also, better management of information recording, better identification of physical abnormalities, providing self-care recommendations, and so on by nurses have scored better than doctors. Other positive evidence has been reported in the United States, New Zealand, Australia, and the United Kingdom (Nanda & Anilkumar, 2021).
Hence, according to the successful experiences of other countries, it is reasonable to use specialist nurses in the patient referral system to achieve equitable health services, especially in areas where access to health services is inadequate. Although there has always been a shortage of nurses in Iran, in many cases specialist nurses perform tasks at the bedside that other non-specialist nurses can perform the same tasks at a lower cost. Meanwhile, the use of specialist nurses in the primary healthcare system can be accompanied by various effects, such as reducing health and treatment costs, improving the social status of nurses in society, creating job diversity, and covering specialist staff in times of crisis and pandemics. Therefore, it is recommended that the use of specialist nurses be first evaluated as a pilot in some centers providing primary health services, and if positive results are observed, it should be widely used.




References
Ahmadifard, M., et al., 2022. [Systematic review of studies on the implementation of the family physician plan in the Iranian health system in the years 2001-2020 (Persian)]. Journal of Healthcare Management, 13(1), pp. 37-57. [Link]
Akbari-Sari, A., et al., 2022. [Factors affecting the acceptance of the referral system by patients: A qualitative study (Persian)]. Journal of School of Public Health and Institute of Public Health Research, 19(4), pp. 365-84. [Link]
Maier, C. B., Aiken, L. H. & Busse, R., 2017. Nurses in advanced roles in primary care: Policy levers for implementation. Paris: OECD Publishing. [Link]
Nanda, L. & Anilkumar, A., 2021. Role of nurse practitioners within health system in India: A case of untapped potential. Journal of Family Medicine and Primary Care, 10(8), pp. 2751-6. [PMID]
Seyed-Nezhad, M., et al., 2022. [Providing a model of acceptance of the referral system from the perspective of patients (Persian)]. Iranian Journal of Health Insurance, 5(3), pp. 200-9. [Link]
Tavakoli, F., et al., 2017. [The effect of health policy and structure of health insurance on referral system in the urban family physician program in Iran (Persian)]. Journal of Healthcare Management, 8(3), pp. 85-93. [Link]