Is the scrutiny of GP referrals justified?

Referral management is increasingly popular among CCGs keen to cut costs. Stephen Robinson asks whether the controversial tactic is working.

Referral management, although not a new concept, is growing in popularity among CCGs struggling with ever-tighter resources.

However, potentially serious errors by referral management centres revealed in a GP investigation add to the controversy already surrounding the schemes.

GP referrals in England passed 12.5m in 2013/14, up 15% since 2008/9. Pressure on commissioners to lower demand on acute and specialist care is intense and referral management centres are seen as part of the solution.

Referral management

Our findings suggest more and more CCGs are turning to referral management. Using Freedom of Information requests, GP asked all 211 CCGs in England for details of referral management centres they operate or commission.

Of the 182 responses, 47 CCGs had a centre. Of these, 64% had been set up since 2010 and 21% since CCGs took control of commissioning in 2013. Half (49%) are run by CCGs in-house, but private firms are also commissioned to scrutinise referrals.

CCGs invest millions of pounds a year in these centres, and a third actively track savings. Yet our investigation found huge variation in costs per referral assessed, from £2 to £60.

In numbers: CCG referral management centres

How is funding changing in 2014/14?


Based on figures from 47 CCGs with referral management centres

Our data suggest one in six GP referrals in England pass through a referral management centre. But the schemes have left GPs concerned - not least because evidence suggests they are ineffective and expensive.

An analysis by the King's Fund in 2010 concluded that 'the greater the degree of intervention, the greater the likelihood that the referral management approach does not present value for money'.

This view was supported by a University of East Anglia study in 2013. The analysis found referral management centres were more expensive than peer review, yet had no impact on outpatient attendance rates.

Against this backdrop, our investigation found 36% of CCGs with these centres reported errors in processing referrals. These included breach of confidentiality, lost referral letters and delays to patient care.

Although the errors affected only a small fraction of all referrals seen by referral management centres, they could expose GPs to potentially serious medico-legal risks.

Referral management centres

What is referral management?
Approaches vary widely, the King's Fund says. Referral management centres represent the most active intervention. Referrals are generally passed to a third party, often a clinician, for triage. They will scrutinise the clinical necessity of the referral and decide where the patient should be seen. In some cases, a centre will only triage based on administrative criteria, such as whether a referring GP supplied all of the required information.

When did it begin?
Referral management emerged from the creation of the NHS internal market in 1991, when GP fundholding forced GPs to take notice of the costs of their referrals. Later, under PCTs, it diversified into many different initiatives aiming to curb demands on secondary care.

Why is it controversial?
Critics argue that adding an extra step to the patient's route through care risks delaying diagnosis. There is also a lack of evidence that referral management is effective.

Source: Referral management, lessons for success. King's Fund, 2010

GP liability

Dr Sally Old, medico-legal adviser at the MDU, says: 'GPs are liable for making an appropriate referral, for indicating its urgency and for ensuring, as far as possible, that the referral reaches the referral management centre.

'The referral management centre is responsible for how it deals with the referral once it is received. If a referral is lost or delayed because of the referral management centre process, the GP may not bear any liability.

'But if, for example, the urgency of the referral was not indicated by the GP or the referral management centre did not receive it and the GP didn't recognise this, the GP may bear some liability.'

There are also concerns about workload. Our investigation found on average 4.4% of referrals seen by these centres - one in 23 - were returned to referring GPs, mostly for administrative reasons, including missing information or attachments, and not fulfilling referral criteria.

In some cases, rates of return are even higher. In the early months of a new referral management centre in NHS Vale of York CCG, 35% of the 5,548 referrals assessed were returned to GPs.

The CCG says the figure is an anomaly because 'GPs were getting used to the process'. A spokeswoman added: 'We are now a couple of months into implementation and the return rate has reduced to 19%.

'Our expectation is that once the referral support service becomes established, the return rate will be no more than 8%.' Even that is double the national average, however. Despite this, the schemes offer many advantages for GPs and patients.

We found many CCGs also provide education and feedback, to help GPs assess and improve the quality of their referrals. CCGs such as NHS Camden CCG in north London are offering incentives to GPs to audit and reflect on referrals.

NHS Bromley CCG, in Kent, introduced a GP incentive scheme in June 2013 to encourage GPs to refer via agreed pathways, such as those for musculoskeletal conditions. This reduced physiotherapy waiting times from more than six months to less than six weeks, the CCG says.

A spokeswoman said: 'The aim is to better manage referrals, so when patients require further treatment or investigation, they are referred appropriately and to the right service.'

Referral management can also, in theory, make it easier for patients to arrange an appointment with a specialist and give them access to care in the community, where this is more convenient. In some cases, it means GPs are no longer required to use Choose and Book, which is handled by the referral management centre.

But some LMCs are adamant the potential benefits do not outweigh the negatives. Last year, GPs at the UK LMCs conference said referral management centres were an 'attack on GPs' professionalism'. This view was backed by 62% of 606 GPs in a poll for this magazine.

At this year's conference, a Devon LMC motion put forward, but not discussed, called for a government review of whether referral management centres are value for money.

Lack of evidence

The motion called on GP leaders to recognise 'the lack of any evidence that the additional work, bureaucracy and costs that referral management centres impose on GPs is of any benefit to the efficient functioning of the NHS'.

GPC chairman Dr Chaand Nagpaul says GP leaders have long had concerns about the centres. 'We know there is evidence that referral management centres have not achieved their supposed aims,' he says, referring to the 2010 King's Fund analysis.

'On the back of evidence from the King's Fund, CCGs should think carefully about using scant resources for referral management systems that may end up costing more than any benefit in the process, and can add bureaucracy and delays to treatment and unnecessary workload for GPs.'

He is particularly concerned about the medico-legal risks and urges GPs to be cautious. 'GPs must at all times remember their GMC duty of care to patients. If they feel local systems are preventing them from providing appropriate care, they need to voice this and challenge accordingly.'

With the pressures facing the NHS in the coming years, referral management as a concept is here to stay, despite the controversy. But what are the alternatives to referral management centres?

Dr Nagpaul says: 'Simply blocking referrals and returning them is not improving quality of referrals; all it's doing is creating obstacles. A peer review and targeted education with local guidelines is likely to be more effective and that's what we would support.'

Expert view - Dr Sally Old, MDU medico-legal adviser

When writing any referral, whether via a referral management centre or direct to a specialist, it's important that GPs are clear about what type of specialist the patient needs to see, how urgent the referral is and what the clinical features of the patient's condition are.

GPs should explain to patients whether their referral will be sent via a referral management centre and obtain their consent for this.

It's important that only relevant information is disclosed with the referral, to avoid unnecessary breaches of confidential information. For example, if referring a female patient with back pain, it may not be necessary to disclose she had an abortion 10 years previously.

Referrals can be lost in the system, so GPs may want to let patients know what to do if they hear nothing within a certain period. If the referral is urgent, it may be advisable for GPs to follow up with the referral management centre if they hear nothing within a set time.

We are happy to advise GP members with queries on referral management centres and advice is available at themdu.com

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