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Referral management ramps up costs but fails to reduce outpatient attendances, find researchers

Referral management schemes fail to cut down outpatient attendances and incur significant costs, a UK study has revealed.  

The three-year study, from April 2009 to March 2012 and published in the British Journal of General Practice, showed that referral management services - such as referral management centres and internal peer review of referrals - failed to reduce outpatient attendance rates and, in one case, actually increased rates.

The study of 85 practices in Norfolk cast doubt on whether the use of referral management services is likely to offer value for money, despite recently being promoted by NHS England, at a time when many CCGs are looking to such services in a bid to cut referrals and hit budget targets.

Researchers reviewed one set of practices that used referral management centres and another set of practices that used internal peer review to manage referrals, involving monthly peer review and feedback to GPs, to see what impact they had on outpatient referral rates.

Results showed that none of the approaches led to significant changes in outpatient attendance rates. On the contrary, one group – which used the referral management service with the largest budget and widest range of activities – had a significant increase of 1.05 attendances per 1,000 patients per month.


The study also found that the costs of running the schemes averaged £0.97 for internal peer review and £5.18 for referral management centres per registered patient in the year 2011/12.

The authors concluded: ‘The lack of effect found by this study suggests that a cautious approach should be taken to adopting referral management, particularly if undertaking a wide range of activities across multiple specialties.

‘Given the widespread use of referral management, evaluation is needed to understand the relative importance of each component in referral-management interventions, if referral management is to be applied effectively to reduce outpatient attendances.’

Dr Chaand Nagpaul, GPC negotiator and a GP in Harrow, said: ‘It really does demonstrate that CCGs need to be careful not to go with gut feelings on how to reduce referrals. In particular, there is no evidence that introducing referral management centres is actually successful in reducing referrals and it adds considerable costs by adding a bureaucratic tier into the process, as well as diminishing the sensitivity of the relationship between the patient and referring doctor.’

Dr Nagpaul added: ‘We need to empower GPs to make appropriate referral decisions rather than have a third-party tier that restricts referrals.’

Dr Helena McKeown, GPC member and a GP in Salisbury, said: ‘What can be useful is discussing referrals that are not cut and dry with colleagues and seeing how you might be able to do things differently, but I’m not a believer in referral management centres.’

She added: ‘What is the point of them if they are increasing costs? Review of referrals can be looked at in-house, or with a few practices getting together – we don’t need managers to scrutinise the quality of referrals.’

Br J Gen Pr 2013; 63: e386-e392

Readers' comments (8)

  • Once again this demonstrates that the most cost effective way of running a health service is to trust the doctors who work in it to make decisions and stop interfering the same applies to pharmacy advisers who are a waste of money today I received an offer to work in Alberta Canada at a remuneration 3 times what hunt and the daily mail think we are worth,British doctors are valued and trusted around the world just not in England and by members of the nasty party

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  • Am I right in thinking that the cost referred to here ( £5.18 per patient per year) is more than the amount paid for OOH cover per patient per year.
    If so...........

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  • I have just come up with the most effective referral management program. It has 100% success rates at reducing referrals. I am happy to offer this to the NHS at a modest cost.

    The idea .... lock the surgery doors and turn off the phones....

    No referrals will then be generated as no work will be done ;)

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  • All barriers to GP seeking second opinions should be abolish , we have a right to refer and there is no evidence that referal managment are good for patients, it is just a delay tactic.

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  • Samuel Lewis

    I too would love to agree that this study drives a stake through the heart of referral management..

    but actually, i thought the idea was to sift out unnecessary and 'inappropriate' referrals . So isn't a sign of success if more of the more needy people get seen more quickly ??

    What I need here is a measure of 'quality' per 100 referred, or better still, a health outcomes index , per 1000 patients and per £1000 !

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  • This study is flawed because its outcome measure is new outpatient attendance, it did not measure impact on new referrals. There is a considerable lag (about 18 months in our experience) between reducing new referrals, and a reduction in new attendance, as waiting times reduce. Even then, unless commissioners decommission, and providers amend clinic templates, new attendances may remain the same as referrals may come in from other sources e.g. consultant to consultant, out of area.
    What this study tells us, is that referral management on its own may not reduce outpatient attendance in the short term. Since this is not the only purpose of referral management anyway (improving patient experience, better use of community clinics, improving learning for doctors, reducing unexplained variation) it cannot be read as a commentary on value for money.

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  • WG Consulting have no doubt that referral management centres do not work - this is just further evidence of that fact. What does work has been clearly documented by the Kings Fund and proven in the WG programme for referral management that has produced a savings to costs ratio of 3:1. The key to a successful programme is to intervene at practice level and change processes behaviours both in the practice and with individual GPs. Peer review an mentoring are a key part of this but so to is the establishment of best pracrtice processes in-house and the use of believeable real time data to both drive the need for, and then reinforce, the required changes. To be effective data needs to be at practice level (where aggregating by speciality is pointless as numbers are to small) and TIMELY - show practices data as they refer measured at the hospital door or as they leave the practice - and IMPACTFUL - raw numbers vary too much show trends and rates v other locality practices. The WG programme has all of this backed up by solid project management that keeps the programme focussed and at front of minds. Changing behaviour is a complex process and requires a dedicated effort and resource - only when these are committed will results follow and they do! Happy to discuss risk/revenue shares on our proven programme see more at

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  • I suspect any drop in referrals due to a new referral management system is only temporary unitl the GPs works out what phrases will allow the patient to get throught the managment algorithm to the correct person in the correct specialty at the correct time.

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