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Up to one quarter of GP referrals ‘avoidable’

Exclusive Up to 25% of GP referrals could be avoided through a combination of better signposting, education, pathway redesign and use of technologies, according to the authors of an audit of referrals carried out by a CCG.

The audit – led by two GPs at NHS Southern Derbyshire CCG – found 15% of GP referrals were inappropriate and could have been dealt with in primary care and another 8% were made before the condition had been fully explored, while a further 1% of referrals were classed as ‘bonkers’ by the authors.

However, they concluded that these avoidable referrals were as a result of ‘busy practices’.

Dr Komal Raj and Dr Callum McLean carried out the audit, in which all 20 practices in the locality sent in GP referral letters for the whole of November 2013 – a total of 1,995 letters weighing 42 kg.

As well as the 15% of inappropriate referrals, and 8% of early referrals, the audit also found 7% were were re-referrals, whereby patients had to be referred again after being wrongly discharged back to the GP.

The 1% of ‘bonkers’ referrals were ‘without focus, value or common sense’ – but these were most commonly the result of ‘proxy’ referrals whereby GPs were told by secondary care to make the referral.

The audit also revealed very marked variation in referrals among practices – with a 400% variation in the total number of referrals and a 2,000% variation in inappropriate referrals – which Dr Raj said showed a lot of the problems were down to some practices struggling with demand.

Dr Raj said: ‘I think it’s just busy practices, they are just so busy they have not looked at different ways to see patients or run their practices, and the end result is you get more referrals and admissions.’

He stressed most of the problems were due to poor communications or pathways and lack of education, and that the aim of the audit was to demonstrate where improvements could be made and put better systems and support in place.

Dr Raj added: ‘It’s not a case of telling GPs off, to say what they are doing wrong, because we’re all really busy and I know what happens, you’re busy, you’ve got a really full clinic and you just end up referring them.

‘What we are trying to do is find a solution to actually support GPs and practices. So one thing we’re looking at it is sending a GP into the practice, not in terms of simple triage but building up a relationship with the practice and looking not only at referrals but if there are issues with visiting rates, IT and all sorts of things.’

Readers' comments (33)

  • a) waste of time and money (42 kg of referrals???)
    b) this CCG is doing exactly what politicians hoped it would - ripping our own colleagues apart. Divide and conquer.
    c) Who has comprehensively proven that more referrals=bad?
    d) what a load of tosh- "it's not about telling gp's off, it's just about supporting them". Absolute codswallop.

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  • You couldn't make it up could you? NHS institutes Patient Charter in which it states patient has a choice to be referred. Couple that with increasing demand and "awareness" campaign with year on year rising complaints/law suites and you wonder why GPs are referring more.

    I would say 15% inappropriate referral is actually quite small. I'd be interested in "inappropriate OPD follow ups in secondary care" which I bet would be higher then 15%. More worryingly 7% re-referral seems high - does this mean secondary care is mistreating the patients?

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  • as others have said : 15% surprisingly low

    considering the demanding type of patients we deal with everyday.

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  • Sorry forgot to put:

    Does this (7%) mean secondary care are mistreating patients or does it represent gaming by secondary care, looking for new patient referral tarrif? I've certainly had a few of them (including please refer back in 2 years time for follow up)

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  • Bob Hodges

    I do these kinds of audits frequently and feel that they have a lot of value, but only if the results are acknowledged to be inherently subjective and any interpretation is made with full declaration of COIs and by GPs who actually see patients themselves.

    They purpose of most utility is to stimulate peer to peer debate. GPs are inherently competitive in my experience and few of us are comfortable being outliers on a clinical basis.

    The most valid observation/interpretation I can see here is that overloaded GPs are more likely to reach for the dictaphone than explore 'pathways' for conditions that they are not familiar with. The solution to the 'problem'? Easy!! More GPs with fewer patients per GP and longer consultations. I'm not holding my breath.

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  • Actually that's pretty good.

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  • Bob Hodges,

    Well said. There is a limit to what I can do in ten minutes. The more overloaded I get the more I refer.

    In fact the more pressure they put me under, the more I refer and the less guilt I feel. This job is becoming impossible.

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  • Vinci Ho

    While I can accept this figure with some reservation and agree that the main problem was limited time for rising demands, I would like to have the figures for 'inappropriate' referrals from secondary care back to GPs e.g. discharge back to GPs after recent operations in hospital.

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  • The audit was actually quite a good read, definitely open to subjective bias but I liked the breakdown for each of the specialties and what common themes/improvements could be made.Pretty soft data but a report I think if folk read any jobbing physician might take something away from it.

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  • Who measures the yardstick about what is appropriate/ inappropriate?

    GPs are not contracted to do as much work as possible, work patients up as much as possible or make sure that as much as possible is done before they see a secondary care physician. That is why secondary care get paid so much per appointment - it is their job to organise and follow those things up. If necessary they could read the referral letter and organise tests before their appointment (but organise it themselves not ask the GP to do so).

    If GPs are doing those things it is worth remembering that it is entirely optional and unpaid. As workload tightens like any other business GPs will more and more stick to the requirements of their contract.

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