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Independents' Day

RCGP calls for referral management centres to be scrapped

The RCGP has called on CCGs to stop commissioning management centres aiming to reduce the number of GP referrals to secondary care.

A review carried out by the college, which looked at existing data and research, found 'no evidence' that referral management was 'cost-effective or safe'.

The RCGP report added that there were 'significant ethical and professional concerns with these initiatives as they can undermine GP professionalism and patient choice'.

It comes as Pulse revealed last year that NHS England planned to incentivise all CCGs to manage referrals and achieve a 30% reduction, although it was later reported to have 'changed its position' in relation to the plans.

The RCGP's review said NHS England 'must not' introduce 'blanket targets and financial incentives for reducing the number of referrals'.

It added that where referral management centres are already in place 'local funders of healthcare must be accountable to ensure their safety and cost-effectiveness'.

The RCGP said that around a quarter of CCGs in England were reported to be using a referral management centre in 2014, over two-thirds of which were set up since 2010.

But the report found that the centres potentially:

  • undermine patient choice and the trust patients have in their GP;
  • cost the NHS more in the future, by sending back to the GP for reconsideration of alternative referral routes or when a patient’s condition deteriorates;
  • undermine GPs’ clinical knowledge and professionalism, and relationships between GPs and colleagues in secondary care; and
  • further fragment the health system and the patient journey.

The RCGP concluded that it 'supports the use of initiatives which are primarily designed to improve referral quality' but 'does not support the use of referral management initiatives which are primarily designed to reduce referral numbers by imposing external control measures onto GP referral'.

The report said: 'There is evidence to suggest that successful approaches to referral support include combinations of local expertise, specialist advice, peer review and reflection, and pathway development and guidelines.'

But it added: 'There is no evidence that referral management, as defined here, is cost-effective or safe. Moreover, there are significant ethical and professional concerns with these initiatives as they can undermine GP professionalism and patient choice.'

RCGP chair Professor Helen Stokes-Lampard said that although GPs 'understand completely that the NHS is strapped for cash', 'good quality evidence that referral management centres are cost-effective does not exist'.

She said: 'What they do is undermine GPs’ professionalism and the decisions we make in the best interests of our patients, and in doing so erode the important trust our patients have in us.'

'They also overlook that only around one in 20 consultations results in a referral – accounting for just over half of all referrals to secondary care. Family doctors will not make referrals without a good reason for doing so.'

BMA GP Committee workforce, education and training policy lead Dr Helena McKeown said: 'These schemes can be inefficient and often create a barrier between the GP and patient as they can be impersonal and not sensitive to the needs of the patient.

'The system which was intended to cut costs and be more effective has instead added extra layers of bureaucracy with many cases being returned to GPs.

'We need to see much more evaluation of how these schemes work as it is ultimately patients who are suffering due to unnecessary delays to care.'

An NHS England spokesperson said: 'The NHS wants patients to get faster access to the right specialist first time. That’s why local NHS bodies are working with their GP practices to develop the type of referral support supported by this report.'

Readers' comments (9)

  • A Guardian reading five year old would have no difficulty detecting "significant ethical and professional concerns......" but this seems to totally escape CCGs.
    When I pointed out that there could be ethical objections to asking all patients if they had private medical cover I was met with hostile incredulity.

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  • Took Early Retirement

    Same was true for Darzi Centres, Walk-in-centres too. But evidence counts for nothing when someone "has a good idea" that might further their career aspirations.

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    It's so sad that CCG'S ARE RUN BY GP'S
    Sometimes we are our own worst enemies

    Another thing that is annoying ...
    setting up reams of bureaucracy
    required with each referral..

    Its not clever !!
    We see the real purpose of it !!

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  • David Banner

    Trouble is many CCGs have poured small fortunes into these RMS companies in the hope of savings down the road. They still send round monthly emails proudly proclaiming how swimmingly RMS is working, whilst quietly closing down old referral pathways they promised would remain open. Meanwhile barn door knee replacements are diverted to that’s progress for you!

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  • I would like to know why this GP has only been given a warning by the GMC whilst Dr Basa-Garba has been struck off the register:

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  • You can't talk sense to GPs who become members of CCGs because they lose their ability to reason. Even a Rheumatology or evident Pain Clinic referral where a patient has raised inflmmatory markers or just needs a rpeat epidural has to be referred to a MSK Triage Clinic which is paid xxx pounds to forward it to the service the Nurse? HCA? deems it should go to - for a charge of course. We need middlemen to take their cut and siphon money out of NHS through these so called Referral Management Service. The more corrupt the region, the more these ideas flourish. And the patient - let's just quote a Primary Care Head 'I don't care what patients say'. 'Pilots' are construed when corrupt imagination takes flight.

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  • If they are going to reject referrals we need a named clinician and complaint number to give to the patient. These referral are often rejected anonymously.
    I always write back and say for the medical legal document could I have a name of the person who rejected it.

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  • Macaque

    One time, a breast augmentation referral for a patient in her early 20s was denied funding by the CCG. One of the conditions for the appeal process was sending a photograph of the patient's breasts!!

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