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Independents' Day

Referral management scheme declined almost a tenth of GP requests

Exclusive Nearly a tenth of specialist referrals were sent back to primary care by a £206,000-a-year private management scheme, a CCG has revealed.

The rapid specialist opinion (RSO) scheme was introduced by North Durham NHS CCG in 2016 to review referrals from its 31 GP practices.

The CCG hired private provider About Health to review referral letters at a cost of £10 a time. It said that unnecessary referrals usually cost the CCG around £150 a time.

In the first 68 weeks of the scheme, GPs and NHS consultants reviewed 17,573 referrals and returned 1,683 to primary care 'with advice'.

The CCG said returned referrals covered ‘conditions that can be treated more appropriately within primary care or a GPSI community service in accordance with our clinical guidelines’.

Cases could include cataract surgery referrals before a patient is seen by a referral refinement service.

‘The referral will be returned to the GP practice for them to advise the patient they will first need to been seen by an accredited optometrist for a full assessment,’ said the CCG.

Another 2,288 - or 13% - were referred onto a GP with special interest (GPSI) or community services for treatment.

Reviewers accepted 13,602 referrals from GPs over the same period.

The CCG estimates that the scheme saved £982,000 in its first year.

‘RSO is to ensure patients are receiving the most appropriate treatment for their condition in the most appropriate place,’ it said.

GPs had a right to appeal the decisions and each referral was expected to take up to three days.

Meanwhile a 12-month pilot referral review scheme used by NHS Darlington CCG and NHS Hartlepool Stockton-on-Tees CCG is still being evaluated.

The CCG told Pulse there was a 7% drop in the number of outpatient appointments for cases reviewed by the Clinical Assessment and Peer Review (CASPeR) scheme in 2017/18, compared with the previous year.

Since the scheme began last summer it referred 1,555 cases and rejected 190 of them.

A team of GPs and GPSI reviewed each case, but urgent referrals were not affected.

It aimed to cut 'variations' in patient care and pressure on hospitals.

The CCGs pointed out that 'this is however attributable to a range of projects' and supports the principle of managing acute demand and seeing patients in the right place, first time.

However a three-year study of 85 practices in Norfolk cast doubt on the effectiveness of appraisal schemes in cutting referrals

Dr Andrew Green, the BMA GP Committee's clinical and prescribing policy lead said: ‘It is quite wrong to judge these schemes in terms of costs incurred set against savings made, what is needed is an assessment of the clinical outcomes of the patients involved.

‘It is appropriate to look at imaginative and cost-effective alternatives to the traditional out-patient referral, but these must not make savings by denying or postponing the care that patients need, by transferring clinical risk to GPs, or by transferring work onto already struggling practices.’

County Durham GP trainer Dr Kamal Sidhu said there was ‘more of a standardised approach to referrals including use of clinical processes/protocols and also an increased use of skill mix within practices’ which could make GPs ‘more focused on what we might achieve from a referral’.

But he added: ‘At the same time, we are in situations where we end up absorbing more uncertainty and risk.'

The news comes as NHS England has been encouraging CCGs to subject GP referrals to peer review.

However, some schemes go further than others, with a Pulse investigation revealing that GP practices in five areas of the country are being offered controversial ‘profit share’ agreements that see them paid up to half the savings if they refrain from referring.

The RCGP 'supports the use of initiatives which are primarily designed to improve referral quality' but has called for the abolition of referral management aimed purely at reducing referrals. It said incentive schemes to reduce referrals have 'no place' in the NHS and were 'frankly insulting'.

Readers' comments (15)

  • I do referral management and I don’t see it as declining a referral. I offer advice on management and always say if this doesn’t help refer back. I do this for about 15% of ENT referrals. I have just stopped working as a clinical fellow in ENT doing general clinics.

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  • Hawkeye

    I wonder who the patient sues?

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  • simnple one Ian. The GP.
    if a referral is declined, then responsibility is passed back to the referring GP. Therefore a declined referral must be referred back immediately if disputed into the hospital. At the same time a complaint must be made to CCG contracts monitoring team each time as there has been an unnecessary delay in treatment to the patient. The patient must also be informed of the delay so that they can also make their complaint known. IF the patient has suffered harm as a result of the delay from the RMC then the RMC doctor is liable. the RMC doc would not have a leg to stand on. Rejecting a referral without seeing the patient is indefensible. ENT cancer can be very subtle. we could be held guilty of manslaughter now.

    we could be brave and gatekeep before Baba Garwa, but times have really changed everything.

    - anonymous salaried!

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  • I'm having some problems with the sums here. 1,683 referrals 'returned' saves £252,450. Less the £206,000 spent on the scheme leaves £46,450, not £982,000. Community referral or GPSI may save a bit more but it's still an order of magnitude less than the claimed savings.

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  • @Mark Howson
    With respect when I write for advice that is what I put in my letter. If I want a patient to be seen then that is what I and my patient expect. I am not a GPWSI in everything so I would imagine some of my referrals are better than others, but I would be surprised if as many as 15% are inappropriate. What is broken about the system is not that there are too many referrals but that there are too few GPs to manage, and (perhaps) too few consultants to receive.
    I think Crown indemnity should be picking up any risks to patients who are bounced back and subsequently come to harm as I don't see why we should fall victim to a game of managerial silly buggers.

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  • @Malcolm
    The saving isn't the issue here.
    But I'm not sure if CCGs have a measure for how much GPs feel like lobsters being boiled alive.

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  • 1) How much is GP time worth?
    2) all of these schemes are sticking plasters. Same with pharmacist in care homes. If GPs have adequate time with their patients, stress goes down, referrals go down, prescribing goes down.

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  • The CCG saves some money by advising GP on how to manage. Meanwhile the GP has to pick up this additional work that would have been done by the consultant.

    Shame, shame on the CCG GPs who are presiding over this.

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  • AlanAlmond

    The savings are for secondary care, but someone is still going to be providing that care, and it’s GPs who will be footing the bill (and carrying the risk) A sizeable portion of the savings are therefore illusory...someone’s providing the care, just not the hospital! Seems to be based on the premis that primary care is ain’t!

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  • Agree Malcolm this is typical CCG economics. Doesn’t add up and no consideration for the time primary care (secretaries, receptionists, gps) have to spend reviewing and actioning the correspondence.

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  • Vinci Ho

    (1)There is a fine line here between improving the quality of referrals and the ideology of throwing a patient forward and backward . Under the current ‘toxic’ working conditions of GPs , the latter certainly will add another caveat to the narrative of general practice being unsafe(the upper limit of how many patients a GP should see daily , prescribing mistakes, opiods/gabapentinoids etc).
    (2) Once referral management(RM)becomes the ‘social norm’ in NHS , it is a no-return road . More robust RM will feed the political narrative/incentive of cutting further resources in secondary care (or even closing more hospitals while I would argue we actually need more hospitals).
    (3) It is also about transferring responsibility from A to B and back to A like a boomerang. I would argue that the RM doctor should personally pass the referral to an alternative clinician(e.g. GPSI) other than specialists in secondary care if he/she deems necessary. If a simple treatment is indicated, he/she should initiate the prescribing for the patient. And if he/she thinks there is no indication to have any specialist opinion(e.g. treatment not covered by NHS),he/she will send a letter of explanation to the patient.
    Yes , do not judge the book by the cover but the judgement also does not sustain without properly balancing the benefits and risks , and more importantly, analysing the current political circumstances .
    Ultimately, deep down ,we all know where the root of the culpability lies for these’ circumstances’ we are under .

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  • Vinci Ho

    And you can criticise me of spinning with soundbites :
    Apart from defending freedom of speech , freedom from fear , this is another one here called freedom of referring for us.

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  • Referral mechanisms have now become so complex that I'm not surprised 10% are in some way misdirected.

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  • Any returned referrals with advice any conditions ccg decides are more appropriately treated in General Practice is automatically a breach of the GP contract

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  • The problem here is that we are seen as a 'free' and limitless resource.
    The most egregious example I have seen locally is when a WIC closure was being discussed, the CCG's Head of Primary Care thought that the GPs should pick up the extra workload without any extra funding (approx 40k patients per year).
    It is probably true to say that in some highly-pressured situations - for safe management of the patient - we refer earlier than we could or than we would like.
    The answer though is either to price our time appropriately so we are no longer a free resource, just the most cost-effective part of the system (come on, GPC, get your act together); or to insist on 20 mins per patient and a fixed number of patient contacts per day.
    I completely agree with the poster who said more time with patients leads to better outcomes, better prescribing, and fewer referrals.

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