A new report from leading health care think tank The King’s Fund has found that NHS referral management centres (RMCs) and some other interventions to manage GP referrals into secondary care are failing to improve quality and deliver cost savings.
Over nine million referrals were made by GPs last year resulting in costs to the NHS of more than £15 billion. The number of referrals made has increased sharply in recent years. Between 2005 and 2009
- referrals to outpatients increased by 19 per cent
- consultant-to-consultant referrals increased by 39 per cent
- other referrals increased by 41 per cent.
Evidence shows that not all GP referrals into secondary care are clinically necessary, or require care to be provided within hospital settings.
Primary care trusts (PCTs) have adopted different strategies to improve the quality and appropriateness of referrals by setting up RMCs, clinical triage and assessment services, offering GPs financial incentives or providing them with clinical guidelines. These interventions aim to improve quality and to reduce costs by reducing unnecessary and inappropriate referrals.
The report reveals that while half of the PCTs studied believed that their referral management schemes had reduced demand for secondary care, those using active referral management strategies such as RMCs, were, in fact, no more likely to achieve this than other PCTs. It also highlighted evidence that some of these schemes could undermine quality, by misdirecting referrals in the absence of full clinical information or by delaying patients’ access to a specialist.
The research found that the more active the intervention into the process of GP referral, the greater likelihood that the scheme failed to deliver value for money. In contrast, successful strategies for managing referrals were likely to include peer review and audit, be linked to clear referral criteria and evidence-based guidelines, and to a system enabling and using feedback from hospital consultants.
Experience from GP fund-holding suggests that GP commissioners will turn to referral management strategies when they take responsibility for the bulk of the NHS commissioning budget, as outlined in the recent NHS White Paper. This report can be used by commissioners as a practical tool to identify suitable strategies for improving the quality and appropriateness of referrals.
Candace Imison, Deputy Director of Policy at The King’s Fund, said:
‘We found that the most interventionist management approaches from PCTs, such as referral management centres, were unlikely to offer value for money and could actually increase overall costs to the NHS.
‘All future GP-commissioning consortia will need to consider referral management options, so we’re pleased that our analysis of what works can be used by commissioners now and in the future to determine which approaches could deliver cost and quality benefits within their local health economy.'
‘Referral management: lessons for success' is the latest in the Quality in a cold climate series of reports from The King’s Fund evaluating how the NHS can maintain quality and avoid cutting services while delivering the £14-20 billion savings needed under current funding projections. The report lays out seven practical principles that commissioners can look to in considering referral management strategies.
Notes to editors
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The research involved data analysis, literature reviews, case study analysis and interviews with PCT personnel working in referral management. The research targeted the PCTs undertaking the most active referral management strategies.
Referral management centres were created by PCTs in England to manage the rising costs of unnecessary or inappropriate hospital referral by GPs by undertaking clinical triage of referrals to secondary care, with powers to redirect or refuse referrals.
The report concluded that successful referral management strategies were likely to include peer review and audit, to be linked to clear referral criteria and evidence based guidelines and to a system enabling and using consultant feedback.
The seven evidence-based principles for commissioners to consider in respect to referral management strategies are:
- 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 clinical hand-off, 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 by local GPs, a strategy to reduce over-referral could and indeed should also expose under-referral and 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 not just target one.
- A whole systems strategy will be required to manage demand, with active collaboration between primary, secondary and community care services.
This report, ‘Referral management: lessons for success’, is part of a series of publications in The King’s Fund’s Quality in a Cold Climate programme, which aims to help the NHS respond to the challenge of unprecedented budget constraints while improving the quality and experience of care and meeting growing demand for health care.
The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas. www.kingsfund.org.uk