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Independents' Day

How we reduced our referral rates by 46%

Dr Michelle Sinclair explains how GP education, cross-referral, targeting locums and use of non-GP alternatives dramatically cut her practice’s referrals

The problem

As with all general practices, we were faced with  inexorable demands to reduce costs, with a growing list of audits, reviews and a feeling of ‘big brother’ watching us.  

Due to a partner retiring in July 2009, over the latter months of 2009 and  then 2010, we started using more locums. In April 2010 to April 2011, our practice steadily climbed to become the highest referring practice in our locality of 22, reaching a staggering 34.8% above target levels compared to the average of an 11% increase amongst other practices.  

What we did

Spurred on  not only by  increasing demands to reduce costs, to audit, review and report, the decision was taken to implement a referral plan that included regular weekly indepth meetings with the practice’s new business and practice manager, educational  in-house sessions, cross-referral to partners with more expertise and heightened awareness of referral statistics.

High-referring specialities were targeted for reduction and subjected to weekly scrutiny until levels reduced significantly.

We monitored the referral activities of our locums and more importantly, educated them on the practice’s plan. We stopped working with any that were persistently high referrers and who ignored our directives.  

We also actively encouraged and educated our patient population as to the availability of alternatives to the lengthy NHS waiting times: complementary private therapists,  counsellors, osteopaths, a physiotherapist, hypnotherapist, reflexologist, and podiatrist were all signposted through the surgery.  


The more militant locums simply wanted their hours and were not interested in reducing practice costs and target levels.  

The weekly reviews increased our manager’s workload, with many hours spent scrutinising target data received from our CCG, making comparisons, reviewing and changing our  referring habits, educating ourselves to scrutinse data, and implementing changes to individual practice.


Our referral levels were increasing annually with some year on year comparative figures showing us as high as +28% compared to the same time in the previous year.  From April 2011 to March 2012 we had reached an overall total for year of +3% above target levels.  However by the following March 2013, in just one year we had significantly reduced our overall total for the year to -18%.

As we surpassed our target levels, others in our locality started to question what was going on. Was the data incorrect, were we using out of area services, just what exactly was the practice doing to have achieved such a dramatic reduction?  We were eventually approached by our CCG and asked if we were willing to become a case study, to share our tactics with neighbouring practices.  

The future

Despite our success, for 2013/2014, the practice still was given higher targets to reach, with the same pressures.  

Sadly our success did not see us rewarded in any way. We have the same cuts, the same financial pressures of doing more for less, but we have achieved the supposedly impossible and believe that these methods for now are sustainable for the immediate future.  

Dr Michelle Sinclair is a GP in Fleet, Hampshire.

Readers' comments (15)

  • All very well and good. But how do you deal with a deprived area who with loads of patients who cannot afford private / complimentary therapy

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  • well done but not patted on the back
    the GMP states that if a patient needs referral then they should be referred
    yes I agree some locums are absolutely non concordant but one of our CCGs use the buddy system and it works well
    my view as a clinical lead is if we want to use alternative therapies we should commission it as we have done MSK tier2--Community Prostate assessment clinics--E D clinics-Incontinences clinic-Community geriatrician and rapid response service-not forgetting the community dermatology and ophthalmology services. We have also created community beds and we follow shared protocols for long term condition with secondary care. We have also put a GP in A&E in front
    clinical lead and tutor Thurrock NHS CCG

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  • I think if I were a patient of your practice I would find a new GP!

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  • Suggest you check out NHS Choices patients' reviews. This gives the practice 2 stars only

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  • hang on now- are you treating the patients or treating the targets? Are you doing your patients any favours by referral to reflexology and osteopathy? if there is a long waiting list for appropriate care should you not be campaigning to get the service improved, not meekly accepting this? Good on the locums who you offensively describe as 'millitant' for not making targets the aim. The moral is as you point out that while you tried to play the target game all you get is another harder target.

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  • It is very sad that the good Doctor is criticized in such an unpleasant manner when she is merely reporting facts.
    You Facts that referrals have been reduced, facts that the NHS have been saved money, a fact that money saved could be well used elsewhere. It is a fact that the money is what I and millions of others pay in taxes, and therefore have a right to expect prudence in its use.
    Patient care has clearly not been compromised as the responsibility for the patient remains entirely with the practice. There is no mention of referral to a complementary therapist, you will be aware that you cannot refer for insurance reasons. These patients have taken responsibility for themselves when consulting a complementary therapist. Could one seriously imagine that they would have continued to pay for treatment had they not felt the benefit in so doing?
    They would of course have returned to the doctor for conventional treatment had they not done so.
    Whatever the arguments for and against complementary therapy one must bear in mind that this is of course a very small sample, however it is an example that others might well benefit in pursuing further.

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  • Of course, the locums may having been catching up with the back log of unreferred patients.
    Being more recently qualified they may be more aware of medical advances and newer specialists treatments that are available.
    Therapeutic nihilism is not a satisfactory option and patients should not be restricted from access to specialist treatments that they may benefit from.

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  • I have met this nasty economic attitude many times pervading the NHS even with the NHS Constitution . How many people with chronic conditions will become acute because of downright negligence . Many will find their lives will be terminated 30 years too soon by no monitoring .The hardest people to treat are those with multi conditions that NHS can't cure so there are complications. Dementia? Patient orientated research is surely the way forward .
    Is this why the hippocratoic oath is not taken ?!Are we all guinea pigs . It appears no longer are our record confidential . Legal ??

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  • Good article but would benefit from some absolute numbers. Reducing by 18% following a previous year 28% rise could be taken as a 10% rise over 2 years which is nothing to write home about. But if the referrals per 1000 patients (raw/weighted) are now a significantly lower number in ABSOLUTE terms than peers then there is something much more interesting.

    Can this data be published?

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  • Could you please report about patient satisfaction and mortality rates on the re-audit i. Secondly, if we all stop referring patient will this lead in to closures of the local hospital and more work loads heading our way with ageing population.

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