GP Referrals - Virtual triage is the way to go

Dr John Havard says external vetting by a specialist centre effectively reduces outpatient bookings.

ENT referrals are sent to a specialist to assess whether the patient can be treated in the community (Photograph: SPL)
ENT referrals are sent to a specialist to assess whether the patient can be treated in the community (Photograph: SPL)

Like all commissioning groups, the Commissioning Ideals Alliance in Suffolk is trying to contain outpatient costs while ensuring patients receive a more appropriate service.

There are established methods that vary in cost - from the referral management centres to GP triage models and community clinics. While there can be difficulties with GP colleagues 'marking' our referrals, there is no doubt that effective triage is key.

Virtual ENT advice clinic
We decided to try a model of external triage from a specialist centre. We started with ENT and chose the Royal National Throat, Nose and Ear Hospital (RNTNEH) in central London as our centre of excellence. We agreed with the hospital to set up a model involving specialist registrar Mr Chris Skilbeck.

With Suffolk PCT's help we opened a Choose and Book advice clinic at the RNTNEH. All GP referrals are sent to this virtual clinic to be studied by Chris. His role is to review GPs' letters, grade the quality and then decide if an outpatient clinic is appropriate. Then he emails his advice to the practice concerned where staff either make a local ENT appointment or print the advice to give to the referring GP. While the advice cannot supersede the wishes of the GP, we agreed to audit all the outcomes.

The process is seamless for GPs since they dictate their letters as usual. The difference is that the virtual advice clinic is selected from the menu rather than the local ENT outpatient department.

London specialist
There is a 72-hour delay before arranging any necessary outpatient appointment while the GP's letter is triaged. We tell patients that we are sending the letter to a London specialist first just in case he can suggest something we could be doing before referring them to hospital, if this is still necessary.

Patients are happy with this.

If alternative community management is suggested, we discuss this with the patient on the grounds of saving them an unnecessary hospital trip.

We hoped that at least 20 per cent of referrals would end up being managed in the community - and that, over the longer term, the new/follow-up ratio would improve as more, appropriately investigated, patients are seen in the clinic. What actually happened surprised us.

The percentage of patients for whom further community management was suggested was modest (15 to 33 per cent out of 223 patients). At first sight this suggested the project had fallen short of expectation, but in fact it was successful as the total referral numbers were substantially down.

We started with just one practice and then extended to two before launching the service for all 65,000 patients in our commissioning group.

Although it is still early days, my practice, Saxmundham Health, had used this system for seven months by November 2010 and referrals were down by 27 per cent. In other local commissioning groups, referrals were rising.

Dr John Havard: 'Our acute trust saw the success we were having with ENT and wanted to play a part with other specialties'

Drop in referral rates
It was clear that advice about community management had little impact, so why were our GPs referring much less?

We looked back at the data to ensure we were comparing like with like, that all hearing aid referrals were included and no other referrals were being made to different hospital trusts. There were no surprises or explanations here.

The only evidence we had to explain the results was anecdotal and from the referrers themselves. It seemed to be a case of: 'When you know your homework is being marked by an external assessor, you tend to ensure the quality is up to the mark.'

We thought about extending the model to other specialist centres for different specialties. We then thought that we should first test the local model with the external model working as a control.

Our acute trust could see the success we were having with ENT and wanted to play a part with other specialties. We wanted to develop the relationship between primary and secondary care clinicians but were apprehensive about the role that management might play in distorting the result and inhibiting community management plans.

However, we have now introduced a new Advice Letter Listing (ALL) project, in which referrals to gynaecology and urology (except for two-week wait referrals and frank haematuria) are sent to a special Choose and Book advice clinic.

Initial results are encouraging with nearly 25 per cent of referrals being given a community management plan for which we pay £33 a time.

We hope to expand the ALL project to more specialties. Six specialties will probably cover 80 to 90 per cent of all primary care referrals. The great merit of the ALL project is that referrals are equally and impartially judged as to which cases could be appropriately managed in the community. This addresses the wide range of referral patterns across the county and even within practices.

High referrers may be referring appropriately because of a more profound subject knowledge. However, the ALL project will sort the wheat from the chaff, and may identify learning needs which GP commissioning consortia can then address.


  • Used by the Commissioning Ideals Alliance, which comprises nine GP practices and 65,000 patients in rural Suffolk.
  • All ENT referrals from the practices go to a Choose and Book advice clinic at the Royal National Throat, Nose and Ear Hospital, London.
  • A specialist registrar advises each referring practice within 72 hours on whether the patient can be managed in the community or an outpatient appointment is needed.
  • In seven months referrals dropped by 27 per cent, while the impact in terms of community-managed patients was modest.
  • Dr Harvard is a GP in Suffolk and chairman of the Commissioning Ideals Alliance
  • Chris Skilbeck FRCS (ORL-HNS) is an ENT specialist at the RNTNEH

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