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Referral management systems lead to delay in urgent referrals, study finds

Referral management systems are holding up urgent referrals and preventing patients undergoing investigations within recommended time limits, according to a study at one acute trust.

The audit by a north-west London trust’s rheumatology department found that referral letters took three times as long to arrive when sent via referral management systems as when GPs referred patients directly.

The excessive delays meant those that turned out to need urgent assessment for potential rheumatoid arthritis were not being seen within three weeks as set out in best practice tariff guidance for early inflammatory arthritis, the study’s authors reported at a recent conference held by the British Rheumatology Society.

In light of the findings, GP leaders renewed calls for an end to referral management, which they said created ‘unnecessary barriers’ between GPs and their secondary care colleagues.

The research team said staff employed by referral management centres were no more expert than GPs at identifying potential rheumatoid arthritis, and the extra delays could be causing harm to patients.

The study looked at referrals received by one consultant over a five-month period, focusing on the delay from the date the patient was referred, according to the GP entry onto their computer system, to the date the referral letter was received by the consultant’s office.

The median time from GP referral to receipt was 13 days when sent via a referral management system, compared with just four days when received directly from GPs by fax and seven days via Choose and Book.

Nearly one in three referrals - both overall (32%), and through referral management systems (31%) - were judged to be urgent by the consultant. However, those that came via the referral management route were unlikely to be seen within the three-week target for early inflammatory arthritis, because by the time the consultant had been able to see the letter it was often impossible to arrange an appointment quickly enough.

The researchers said: ‘A 13-day delay makes it extremely challenging to see patients within three weeks from referral date, in a specialist clinic occurring only once weekly (e.g. early arthritis clinic). This makes achieving the best practice tariff standards difficult or impossible.’

They added: ‘Our study has highlighted the necessity for reform in this area. The complexity of referral pathways can delay care, and could allow harm to come to our patients.’

Dr Dermot Ryan, a GPSI in respiratory medicine in Loughborough and NHS respiratory lead in the East Midlands, said the findings chimed with his experience of referral management systems across a range of clinical areas, and that they were being used simply to ration care.

Dr Ryan said: ‘I’m sure this is true across the board, in other clinical areas. Clinicians employed by the referral management centres do not have the necessary skills to pick out those that need referral urgently, and those that don’t need to be referred at all.’

‘You have to recognise the referral management has been put in as a way of rationing care – that’s the whole idea behind it, to slow the whole thing down, it interferes with proper clinical practice.’

He added: ‘I’d prefer to get rid of referral management altogether. But of course, the resources need to be there to accept all the referrals.’

Referral management systems were brought in ostensibly to reduce disparities in practice referral rates and so cut costs. However, a study published last year found referral management services did not curb demand and actually increased costs significantly, while a Pulse survey from 2012 revealed nearly half of GPs believed patients were suffering as a result of delays caused by referral management schemes.

The GPC said the latest study highlighted ongoing concerns about referral management, and said it would be better to introduce closer working between primary and secondary care.

Dr Richard Vautrey, deputy chair of the GPC, said: ‘We have repeatedly raised concerns about referral management systems and the unnecessary barriers they place between GP and consultant.’

‘We should instead be promoting greater collaboration and co-operation between primary and secondary care which would be to the benefit of the care we jointly provide our patients.’

Rheumatology 2014; 53: Abstract 51

Readers' comments (5)

  • Vinci Ho

    Rheumatoid arthritis patients are one of those who suffer from this fallacy of efficiency saving . NICE requires newly diagnosed rheumatoid arthritis patient to be commenced disease modifying drugs ASAP . This has not been fulfilled as far as my patients are concerned, particularly we have access of anti-CCP antibody blood test in community.......

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  • Vinci Ho

    According to NICE
    There is already a delay of 3 months between onset of symptom in RA and seeking medical advice .....

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  • They dont work for any condition full stop. Inflammatory Arthritis should be a 2ww like cancer anyway.

    So CCGs should forget about them

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  • Provision of urgent rheumatology services is very poor to non existent anyway.Any swollen joint should be seen by rheumatology on the SAME day.Not all septic joints result in fever or raised inflammatory markers and some can even be polyarticular:all potential pitfalls for the unwary with serious medico-legal consequences

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  • Took Early Retirement

    Gosh 10.27- that's stretching it just a tad, don't you think? "any swollen joint"? I would still like to make a go of diagnosing acute Gout myself. When I woke up one day with an acutely swollen PIP joint of my left middle finger 2 years ago, I didn't think, "I must get to Rheumatology ASAP". Just my humble opinion though- I might be out of date.

    Retiring in 19 hours.

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