Good referral management doesn't opt for blanket restrictions on access to hospital, but instead relies on good communication and data analysis. Helen Northall describes three successful approaches
Referral management may be controversial, but there are examples of innovative schemes where better design of care pathways and efficiencies are achieved side by side. Success may be measured in different ways — by reduced attendance in secondary care, provision of more appropriate local services in the community or reduction of unwarranted variation in quality of care and spending.
Every success story – including the three case studies included here – exhibits some or all of the following factors:
• a high degree of engagement of GPs
• involvement of primary and secondary care clinicians, other clinical staff and professionals in design and development
• willingness to share information
• availability of data-analysis tools and expertise.
Case study 1
Cumbria – data sharing
In Cumbria, GP commissioners have worked with the PCT to find an effective but relatively low-tech approach to managing referrals. By sharing data, local practices are building up an evidence base for when referral is appropriate and when it isn't. Initially, the project focused on elective care and outpatient referrals but was broadened to include low-priority procedures.
The scheme had a number of goals that appealed to GPs, including:
• systematic and consistent use of evidence in referrals
• better design of care pathways based on good practice and more effective information sharing
• better use of community services and GPSIs.
To build the evidence base, each practice submits a plan of activity for the coming year for specific areas. Clinical activity in those areas is then recoded in an Excel spreadsheet by practices.
Two years after it was launched, all but four of the area's 91 practices were taking part in the scheme. The high level of engagement was attributed to three factors: an existing strong base of practice-based commissioning in the county, widespread recognition by GPs of the need for evidence-based referrals and the availability of an incentive for GPs in the form of a local enhanced service.
The LES for Cumbria's Referral Support and Pathway enhancement scheme lists five principles which could serve as the foundations of any primary care referral management initiative:
• do better in primary care those things we ought to be doing
• better select which patients we refer
• better select where we refer patients to
• improve the preparation and quality of information that follows the patients on their referral journey
• by practising quality, we reduce waste, free up the money we need to develop new services and achieve financial control of our finite budgets.
To qualify for the LES, practices had to agree both to use the referral scheme's Excel-based data collection template and a standard referral letter designed to improve the consistency of information presented to consultants. Each practice also had to commit to produce an annual report identifying three pathways or processes for improvement.
A real innovation of the scheme was the appointment of so-called clinical interface managers – employed by the practices rather than imposed by the PCT. They brought a range of expertise to bear on the evaluation of clinical pathways, and handled communications between the practice and the commissioners. In some cases these were appointed from within the practice, in others they came from non-clinical backgrounds, including retail and education. The managers have had an important co-ordinating role, but just as importantly a remit to challenge assumptions and behaviour. The leaders of the Cumbria initiative did not set out to reduce referrals, but to make them more appropriate by improving both the evidence base for the decision and the consistency of the data used along the care pathway. An early win was a 40% reduction in endoscopy for patients under the age of 55 with dyspepsia.
Case study 2
Sentinel – developing referral guidelines
Sentinel, a Plymouth-based consortium and first-wave pathfinder, has brought together GPSIs, hospital consultants and healthcare managers to develop a set of referral guide-lines spanning a wide range of procedures.
Formal guidelines for referrals enable closer working relations between primary care and secondary care and mean that redesign of pathways can be built on firmer foundations. Priorities include establishing clinical commissioning groups involving consultants, a Sentinel member and a GP with an interest in that area to redesign pathways according to the Map of Medicine, an online tool which allows GPs to plot care pathways.1 Map of Medicine allows commissioners to systematically analyse evidence on the impact of changes to clinical pathways (see Practical Commissioning for detailed evidence summaries).
Guidelines developed so far include those for dermatology services and minor surgery, which have been updated to include low-value, low-priority procedures. The guidelines make clear exactly what can and cannot go through the referral gateway. The referral guidelines for referrals to knee and shoulder clinics and spinal clinics have recently been rewritten and updated partly because of concerns that GPs were overusing ultrasounds for shoulders and MRI for spinal pathways and knees.
GPs tended to request these procedures before doing the referral, in the belief that it would make for better referrals. In fact, the evidence suggested that it simply resulted in more diagnostic procedures than were needed. Referrals now go into the intermediate care service where a GPSI or other clinician then makes the decision about whether to investigate further.
All referrals are subject to regular peer review, as are overall referral levels. Since Sentinel was established all referral levels have been at least flat, but in many areas have decreased. Sentinel is now bringing secondary care clinicians into the process. Consultants pass management to primary care without ever having to see the patient face to face. Sentinel is now proposing to work with other teams, including neurology, to reduce outpatient attendance.
Case study 3
NHS Wirral – tracking patients with real-time data
NHS Wirral worked with local commissioning groups on a management information system to allow GPs and commissioners to share up-to-date information on the care of individual patients and the overall pattern of services.
The system has three key features:
• it is highly accessible – all the area's GPs can access it on their desktops
• it is web-based and flexible, with the ability to slice data as clinicians need – critically, it allows activity to be viewed by individual data and by individual patient
• the data is never more than two to three weeks' old, giving a very accurate picture of the demand being placed on services.
The supply of fresh data allowed the group to improve prescribing management, outpatient follow-up activity and patterns of service use across primary and secondary care. The data was obtained through co-operation with the main acute provider, with open-book principles applied to allow commissioners to view and analyse data to ensure information was being properly recorded. Giving commissioners direct access to patient administration systems in hospitals and monthly updates also contributed to the project's success.
Generic tools are sometimes criticised for their lack of detail and local relevance. But Wirral involved local GPs in the design of the system and the result is that users can take a deeper view through purpose-built reports. For example, GPs can view readmission rates within 14 days and compare new to follow-up outpatient ratios. The former allows GPs to take a much more considered view of quality of care, while the latter enables clinically led monitoring of outcomes and contractual measures to cap follow-up activity.
Individual patient data can help GPs to understand not only where variation is occurring, but also why – allowing them to plan appropriate interventions. For instance, one maternity client was coded as receiving 37 N12 episodes of less than 10 minutes' duration, prompting clinicians to put care arrangements in place closer to home. The system is also credited with first-year savings of £400,000 from the area's bill for acute services.
Getting clinicians to work together on the system helped reinforce already high levels of clinical engagement and led to further benefits, including better management of prescribing, which drove down C. difficile infections.
Helen Northall is chief executive of Primary Care Commissioning, a training and development organisation for commissioners and providers
Referral management
