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Lessons for success


12 January 2011

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General practitioners (GPs) make more than 9
million referrals to hospitals for elective (planned) care each
year (1), referrals that then trigger billions of pounds of
National Health Service (NHS) spending. As budgets tighten
and GPs assume their new commissioning responsibilities,
GP consortia may look to referral management as a way of
controlling costs.

Research from The King's Fund (2) suggests that
referral management has the capacity to either help or

General practitioners (GPs) make more than 9
million referrals to hospitals for elective (planned) care each
year (1), referrals that then trigger billions of pounds of
National Health Service (NHS) spending. As budgets tighten
and GPs assume their new commissioning responsibilities,
GP consortia may look to referral management as a way of
controlling costs.

Research from The King’s Fund (2) suggests that
referral management has the capacity to either help or
hinder clinicians in delivering high quality care, and unless
done well may also increase rather than decrease costs.
So how should GPs take forward an approach to referral
management?

There is significant scope for quality improvement in
referral. For example, some referrals are not directed to the
most appropriate destination, there is not always adequate
information in referral letters, and in some cases insufficient investigations are performed in primary care prior to
making the referral. Also, not all referrals are necessary in
clinical terms and a substantial element of referral activity
is discretionary and avoidable. Patients with identical
conditions may be appropriately managed by one GP but
referred by another, if the GP who makes the referral does
not have the skills and supporting infrastructure to manage
the patient safely. However, there are also many patients
who need a referral but fail to receive one. The result is
a substantial variation in the rate of referral. Studies have
reported up to 10-fold variation between the rates at which
GPs refer to a particular specialty within a single geographic
area (3; 4).

Current approaches towards referral management include
anything from dissemination of referral guidelines to fullblown
referral management centres which review and triage
all GP referrals (see figure 1).

What impact has referral management had?
Our research showed that all referral management
approaches have strengths and weaknesses (see Table 1)
The greater the degree of intervention in the referral
process the greater the likelihood that the referral
management approach does not present value for money.
Full scale referral management centres in particular appear not to be cost-effective. Understanding variation in referral
rates and quality, benchmarking performance locally and
nationally, is critical. In our view a referral management
strategy built around peer review and audit, supported by
consultant feedback, with clear referral criteria and evidence
based guidelines is likely to be the most cost and clinically
effective.

Other opportunities include the use of decision-support
tools. These can sit on a GPs laptop and provide them with
relevant advice and support at the time that they make
referrals, in a similar way to prescribing advice. Products are
now coming on to the market to do this. The use of financial
incentives can also be effective, but if used to drive blanket
reductions in referral rates there are risks that they drive
reductions in necessary as well as unnecessary referrals.

A final lesson from our research is that to manage
referrals effectively requires a whole systems approach.
It is evident that demand for secondary care cannot be
controlled through primary care referral mechanisms
alone, since any reductions in GP referrals can be offset
by increases in consultant-to-consultant referrals. Any
commissioner interested in controlling the volume of activity
in secondary care needs to consider all referral routes and
not target just one.

Conclusion
The large variations in referral practice that exist between
GPs point to the potential that exists to improve quality and
save money through referral management. However, if done
crudely referral management can create more problems
than it solves. To be effective, referral management requires
careful planning and, crucially, needs to be owned and
implemented by GPs and other clinicians.
We list below (See Box 1) some of the principles and
initiatives which should help GP Consortia to maximise
the benefits from the introduction of active referral
management.

Principles for successful referral management
• Any intervention to manage referrals cannot look at the
referral in isolation but needs to understand the context
in which the referral is being made.
• Changing referral behaviour is a major change
management task that will require strong clinical
leadership from both primary and secondary care.
• There are inherent risks at a point of referral, and any
referral management strategy needs to have robust
means to manage those risks.
• There may be just as much under-referral as over-referral. A strategy to reduce over-referral could, and indeed should, expose under-referral. This will limit the
potential reductions in demand.
Commissioners should not introduce financial incentives
to drive blanket reductions in referral numbers.
• Reductions in referrals from one source can be negated
by rises in referrals from other sources. Any demand
management strategy needs to consider all referral routes
and not just target one.
• A whole systems strategy will be required to manage
demand, with active collaboration between primary,
secondary and community care services.

Specific opportunities for PCTs and GP commissioners
to drive improvement
Referral Pathways
• Focus more on reducing procedures of limited
clinical value.
• Review clinical pathways to highlight evidence that
supports alternative and less invasive treatments
• Collect more robust information on patient needs and
use this to redefine patient pathways
Support for GPs
• Improve the information that is collected and fed back
|to GPs, for example, showing comparative referral rates
by specialty.
• Have a website and provide access to up-to-date guidance,
protocols and guidelines – accessible on GPs’ computer
systems.
• Develop the opportunities for increased access to
informal specialist advice to avoid the need for referral
– for example telephone help lines or an email advice
facility
• Develop a more structured approach to mentoring,
supporting and feeding back to practices about referrals
– based on more structured quality markers
• Provide educational peer support role, and possibly
working with geographical areas or groups of practices
• Encourage and support GPs to make sure all appropriate
investigations have been done before first outpatient
appointment
• More targeted interventions with poorly performing
practices
• Provide access to decision- support tools

Support and development of clinical triage
• Create greater consistency in the way in the clinical triage
function works – making greater use of evidence-based
guidelines.

Support for Patients
• If referral are to be managed through a central facility
ensure easy access by phone for patients – with extended
opening hours and rapid response to phone calls.
• Ensure there is adequate support for people for whom
English is a second language.
• Allow patients to track the progress of their referral via
the web.

[[referral management table 1]]

[[Figure 1]]

References
1. Hospital Episode Statistics 2008/9, The NHS Information
Centre, http://www.ic.nhs.uk/
2. Imison C, Naylor C Referral management: Lessons for
success, London: The King’s Fund; 2010
3. Ashworth M, Clement S, Sandhu J, Farley N, Ramsay R,
Davies T ‘Psychiatric referral rates and the influence of
on-site mental health workers in general practice’. Br J Gen
Pract. 2002; Vol 52, no 474, pp 39–41.
4. Creed F, Gowrisunkur J, Russell E, Kincey J. ‘General
practitioner referral rates to district psychiatry and
psychology services’, Br J Gen Pract 1990; vol 40, no 340,
pp 450-4.

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