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Independents' Day

Focus on: The rise in GP referrals

As the DH investigates a 16% rise in GP referalls, Pulse examines a number of theories for the worrying increase

By Lilian Anekwe

As the DH investigates a 16% rise in GP referalls, Pulse examines a number of theories for the worrying increase

Dr Ann Bowman's patient has a worrying skin lesion that may be a melanoma, but that is no guarantee of a quick hospital appointment.

She has been asked to refer the patient – who has already had a melanoma excised once – all over again before a consultant appointment will be arranged.

‘Our district hospital insists on new referrals for everything, even for patients already attending,' says Dr Bowman, a GP in Blackburn, Lancashire.

It is no wonder, as Dr Bowman says despairingly, that GP referrals are going up.

Pulse has been inundated with stories like hers since we revealed PCTs are threatening to slash primary care spending on the back of a jump in GP outpatient referrals, which is threatening to have a dire impact on their finances.

Figures from the Department of Health show the number of referrals by practices increased by more than 350,000, or 16%, in the first quarter of this year compared with the same period in 2007/8.

Those numbers have sent shivers down the spines of NHS chiefs, as have the overspends of up to £5m that are emerging in some PCTs.

The rise in referrals is double that seen in other areas of the NHS and has prompted an urgent investigation by the DH.

A number of possible reasons have been suggested for the increase. One of the most popular is that trusts are so determined to meet the 18-week target that they are insisting on internal referrals.

And they may also be clearing our beds by discharging patients out of hospital too early and with too little specialist supervision, with that workload increasingly shifting onto GPs.

There is evidence for such a theory. Figures obtained by Pulse from the NHS Institute for Innovation and Improvement show that patients are spending less time in hospital, while emergency re-admissions jumped by 6% in the last quarter of 2007/08, compared with the same period the previous year.

The figures show the proportion of day cases is increasing, up to 75% in the last quarter of 2007/08 from 73% in the same period in 2006/7. And the ratio of follow-up to new appointments is falling, down from 2.5 to 2.2 over the time period.

Dr Jonathan Fielden, chair of the BMA consultants' committee, says there is pressure on trusts to ‘push people out early' and this may be having an effect on emergency readmission figures.

‘There are multiple reasons for an emergency readmission, but it is one of the markers that suggests an organisation should look at their discharge policy.

‘It comes back to our repeated criticisms of a target culture, if you just look at the target of reducing your 18-week waits you may push people out too early. Yes, you are reducing waiting times, but people want quality time in hospital and a quality discharge and not to have to come back in,' he says.

Dr John Ashcroft, a GP in Ilkeston, Derbyshire, and vice-chair of Derbyshire LMC, claims hospitals are manipulating the 18-week treatment target figures by cancelling appointments for follow-ups in existing patients, in favour of taking on new patients. He says the readmissions figures show how targets distorted the goals of care.

And Dr David Chesover, a GP in Maidstone, Kent, says it is becoming common place for GPs to have to re-refer patients to have post-op reviews, with policies aimed at hitting the 18-week target and driven by secondary care priorities, leading to an inevitable increase in re-referrals. ‘Sadly.' He says, ‘I am sure general practice will continue to be blamed.'

But the 18-week target does not seem to be the only culprit. While some patient care is moving from hospitals to the community, a series of clinical guidelines are shifting certain procedures in the other direction.

GPs have been heavily criticised recently for the quality of minor surgery, for instance, with many now apparently more inclined to refer patients than operate themselves.

Earlier this year a Health Technology Assessment found operations conducted in primary care were of poorer quality, and were less cost-effective, than those done in hospital.

The research – which examined 637 dermatological procedures and 17 operations on ingrowing toenails –fuelled a growing row between GPs and specialists over whether GPSIs should be able to take on surgical work.

GPC chair Dr Laurence Buckman, says GPs have been ‘demonised', citing NICE referral guidelines for suspected cancer, which state that all suspected patients presenting with skin lesions ‘suggestive of skin cancer' should be referred to hospital, as a classic example of GPs being put in an impossible situation.

Yet there is no doubting where the blame lies according to NHS chiefs. Last week NHS South Central reported its concern at a financial position which had already cut £5m off its forecast.

A report to its latest board meetings says: ‘Growth in GP referrals and the subsequent increase in elective activity is a cause for concern because of the impact on PCT budgets.'

Northamptonshire PCT told Pulse it was looking at making cuts in its primary care budget because of a 13% increase in GP referrals.

Meanwhile the Department inquiry will be given extra incentive by the latest figures which show waiting times for patients for outpatient appointments have begun to creep up, having previous fallen steadily over the last few years. The number of patients waiting 13 weeks plus rose by more than 30,000, to approaching 900,000 at the end of July.

For GPs involved in practice based commissioning, the increase in referrals could have another impact, this time hitting them in the pocket, with some PCTs, such as Westminster, already ordering PBC clusters to crack down on practices seen to over-refering in areas such as endoscopy, ophthalmology and dermatology.

Incentives under PBC to cut referrals have been working in some areas. Dr Shane Gordon, a GP in Tipton, Essex and chair of the Colchester PBC group, said the incentives offered in his area had cut referrals by a fifth.

‘In my PCT referrals fell from 24,000 15 months ago to 20,000 in May. I think a lot of that is down to PBC. We have reduced our total number of attendees to consultant appointments by about a fifth. We have a scheme which incentivises reviews of referrals and that's been extremely successful.'

But PBC is notoriously patchy, and Dr Stewart Findlay, a GP in County Durham and chair of the Durham Dales PBC cluster, is not surprised that the greatest reductions in referral rates are seen in areas where PBC is invested in the most.

‘In most areas across the country PCTs have failed to give the savings, or even a share of the savings, back to GPs because PBC has not been taken up. So there's no incentive for GPs to go that extra mile before referring.

‘We have to remember that this is a very fine line that we walk. The last thing that should be done is to discourage GPs from referring', he adds

For Dr Mike Dixon, chair of the NHS Alliance, the rise in referrals is symptomatic of wider problems than the failures of PBC.

He claims it is the result of months of conflict between GPs and the Government, a battery of new clinical guidelines and GPs' general disillusionment, which leads to a ‘well, lets just refer' mindset.

Whatever the reason for the jump in referrals, it is making PCTs and SHAs increasingly nervous about balancing the books. And as GPs well know, when managers get jumpy, further conflict is likely to be round the corner.


How much have referrals risen?
Department of Health figures show the number of GP referrals increased by more than 350,000 in the first quarter of 2008/09 against the same period last year, an increase of 16%. But referrals from other areas of the NHS only increased by 8% year on year.

The reasons behind the rise are complex. Secondary care targets and policies, such as Payment by Results, pre-operative reviews and the pressure to reduce waiting times and bed days, may result in the same patient being referred several times. There also appears to be increasing patient demand for secondary care services, fuelled in part by shortening waiting lists. And there are more people, such as nurse practitioners and urgent care stuff, working in primary care who can instigate referrals.

What can be done?
The Department of Health is investigating the rise and putting huge pressure on SHAs and PCTs to act to prevent their finances plunging back into the kind of chaos of a couple of years back. Primary care budgets in many areas could face cuts – particular PBC budgets – if GPs are found to persistently ‘overrefer'.

PCT measures to cut referrals

Northamptonshire PCT – Have plans to rethink its investment in primary care services to fund the increasing hospital workload. ‘Our plans to invest resources in community and primary care based services and prevention will need to be rethought if the required investment in acute services maintains at this level', a spokesperson said.

Westminster PCT – Has instructed PBC clusters to investigate practices in high referral brackets for endoscopy, ophthalmology and dermatology. ‘It was clear some practices were consistently in the high referral bracket regardless of specialty and this should be analysed by clusters. Targeting practices with high referral rates would be a helpful measure.'

Warrington PCT – Is looking into ‘Possible referral rate improvements… with the suggested use of telemedicine. The aim of which would be to substantially cut inappropriate referral rates by offering email consultations for minor skin complaints.'

East and North Hertfordshire – PBC [check] groups asked to monitor referral rates and follow-up appointments to London Trusts and Foundation Trusts and identify if these were ‘all appropriate'.

Some PBC clusters have been told to cut referrals in areas such as minor surgery Some PBC clusters have been told to cut referrals in areas such as minor surgery

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