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Radical new gateways reject one in eight GP referrals

By Ian Quinn

Exclusive: GP practices are seeing as many as one in eight of their referrals diverted or rejected, under radical new ‘total referral management' schemes brought in by NHS managers and new consortia, a Pulse investigation reveals.

There has been a huge expansion in schemes restricting access to hospital services over the last year, with four in five primary care organisations now saying they have introduced referral gateways.

Some schemes are being ramped up to new levels after managers admitted earlier versions had failed to achieve sufficient savings, with GPs in one area facing restrictions on 213 different procedures.

Several of the 32 primary care organisations responding to Freedom of Information requests employ private companies to review GP referrals, while fewer than half of schemes use local GPSIs. Others controversially rely on local consultants, nurses or administrators instead.

Among 360 GPs responding to a Pulse survey, 31% said they were now facing restrictions on referrals for IVF, 21% for hip and knee replacements, 13% for cataract surgery and 12% for allergy services.

A third of GPs said they were aware their referrals were being screened by a referral management centre. The same proportion have been issued with instructions by their local GP consortium on referrals policy.

One trust, NHS South West Essex, has written to GPs telling them 213 different procedures – ranging from allergy treatment to hysterectomy – will no longer be funded except in exceptional circumstances. GPs in the area have had 12% of referrals blocked – 4% diverted to another health professional or provider, and 8% rejected outright – since GP-led commissioning group Fortis Healthcare began running a referral gateway for the majority of practices.

Dr Anil Chopra, a local GP and medical director at NHS South West Essex, said: ‘The service restriction policy is part of a plan agreed with local doctors to bring referrals down to a more manageable level. We anticipate we will reduce spending by £1.9m this year.'

NHS Harrow is piloting a ‘total referral management system' in three GP practices after admitting referral management to date had ‘failed to deliver expected savings'. The PCT is targeting £18.3m of savings in 2010/11, including a target of £3.4m in ‘unscheduled care and admissions avoidance'.

Other trusts claim referral gateways have already proved successful at driving down costs. NHS Bournemouth and Poole said its referral gateway had reduced dermatology referrals by 18%, trauma and orthopaedics referrals by 27% and ENT referrals by 31% between the first six months of 2009/10 and 2010/11.

But Dr Mahesh Kamdar, a GP in Canvey Island in Essex, said ramping up referral management was a ‘recipe for disaster': ‘Patients will realise that their referrals are not going through as fast as they have done, so I'm sure there will be a backlash.'

Dr Rachael White, a GP in Enniskillen, Northern Ireland said referrals were being squeezed even in areas untouched by the NHS reforms.

Dr Nigel Watson, a GP in the new Forest and chair of the GPC's commissioning and service development sub-committee, said referral management was necessary in the current financial climate, but would only work if it was professionally-led. He said: ‘Either we get a handle on it or services will get cut.'

DH spokesperson said: 'Clinicians should make referrals based on the needs of their patient and NICE guidelines.

'We are committed to devolving power and responsibility for commissioning services to GPs, who are best placed to ensure patients get the high quality care they need. Aligning clinical decisions with management of resources will lead to more effective referrals.'

Editorial comment

Crude referral blocks won't save NHS

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