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What is going on with referral management?

Referral management centres are being replaced by PBC schemes – but these can bring their own problems.

By Lilian Anekwe

Referral management centres are being replaced by PBC schemes – but these can bring their own problems.

At its most streamlined, a GP's job is admirably simple. GP sees patient, GP treats patient. And if the GP can't, the patient is referred to someone who can.

But in today's NHS, nothing is ever that simple. As demand for ever more complex secondary care services outstrips increases in funding, policymakers are seeking ways to manage demand and make the flow of patients through the system as smooth and efficient as possible.

Referral management is one means of coping with that demand. In theory, referral management systems ought to divert referrals to underused but more cost-effective services, spreading demand efficiently. Whether they manage that, however, is open to question, with concerns that many schemes can constrain a GP's clinical freedom.

Different areas have, inevitably, adopted different forms of referral management. In March 2006, a BMA survey of LMCs found a wide variety of models operating across the country. In Oxfordshire, a clinical advice and liaison service vetted all routine and some non-emergency referrals, whereas in Hastings and Rother, any referrals not met within a 13-week target were diverted to the PCT.

Dr David Keene, a GP in Stoke Newington, north London, is keen to trumpet the model used in City and Hackney PCT, where he is director of clinical assessment.

‘City and Hackney has established a referral management centre to screen referrals by skilled clinicians, GPSIs, extended scope physiotherapists and clinical nurse specialists,' he says. ‘About 50% of referrals can be managed in primary care by these physicians.'

But the BMA has long accused referral management systems of unfairly rationing referrals and interfering in the patient care pathway. Its 2006 survey found more than half of LMCs had ‘significant concerns that referral management will lead to a loss of clinical autonomy, with managerial rather than clinical grounds for referral and possible compromise to patient confidentiality'.

Similar sentiments were expressed in a BMJ editorial a month later, when Professor Glyn Elwyn, research director in primary care at Cardiff University, called referral management systems ‘trojan horses, seeming to offer benefits while silently eroding aspects of clinical practice'.

He warned: ‘If referral centres decide where and if patients are referred, doctors may worry that their freedom is being eroded and patients may worry about the lack of choice.'

Fast forward to February 2008 and Professor Elwyn says there is still no way to assess whether referral management schemes have delivered on their promises – of decreasing risk, increasing efficiency and offering more choice.

‘We don't know if they lead to a lack of clinical autonomy or not – there's very little evidence on which to measure the achievements of referral management centres against any set of meaningful objectives.'

An evaluation by Professor Elwyn and Cardiff-based consultancy firm CRG Research of Welsh pilot schemes suggested that where referral management works best it is on a local scale – concluding that ‘given the differing complexities of clinical specialities, a blanket rollout would be inappropriate'.

So in 2008, it seems, City and Hackney's referral management centre is the exception rather than the rule. Since the 2006 BMA survey, use of specific centres has declined, and GPs are seeing other systems emerge – notably through practice-based commissioning.

‘With the advent of things like PBC and Choose and Book, it became a bit pointless,' says Dr Pritpal Buttar, a GP in Oxfordshire PCT, which has now abandoned its clinical liaison service. ‘You would be achieving the same purpose if you encouraged people to do PBC.'

Shift to PBC

The extent of the shift became evident last month when a National Primary Care and Development Centre (NPCRDC) report found that out of 73 PCTs, 36% had already introduced new referral management systems as a result of PBC, 43% had schemes in the pipeline, and 19% had ‘some form of practice level referral system' in place. Only about 10% were using referral management centres.

PBC's cheerleaders enthusiastically point out that it offers significant opportunities for effective referral management.

Dr James Kingsland, chair of the National Association of Primary Care, says: ‘The whole idea of PBC is to internalise referrals and absorb them into practice. After all, why should a PCT or external triage system make clinical decisions for us?'

Dr Alan Brook, a GP in Brighouse in West Yorkshire, argues that PBC has given GPs back the clinical autonomy that referral management systems threatened to take away.

‘We never agreed with referral management schemes because they were crude and clumsy. They take responsibility away from GPs, which is an anathema to many of us.

‘PBC is a more appropriate mechanism. We monitor and audit referrals, and through that scrutiny can reduce inappropriate referrals. Choose and Book – when it works – can reduce inappropriate referrals by flagging up alternatives. And of course, the carrot of PBC is we don't have referral management systems imposed on us.'

NHS Alliance chair Dr Mike Dixon thinks the success of PBC may lie in its simplicity. ‘The basic and most common elements are that, within the practice or the consortium, GPs get together and analyse each individual GP's number of referrals per discipline, compare the data and identify high and low referrers, and then identify referrals that could be managed better in the community or elsewhere other than hospitals.'

Dr Joe McGilligan's PBC consortium managed to redirect 5-10% of referrals away from secondary care clinics and into GPSI or community-based schemes. ‘I do a lot of the minor surgery referrals, because I have a service in my practice to do it,' says Dr McGilligan, a GP in Redhill in Surrey. ‘So whereas before that referral would be managed by some system within the PCT, GPs now refer them to me. Same with orthopaedics – 80% don't need to see a surgeon.'

But managing referrals through PBC can bring a whole new set of problems. The potential conflicts of interest were highlighted most recently in a scheme in Liverpool PCT, where GPs reportedly referred dermatology cases to private providers in which several commissioners had financial interests. There are also concerns that by diverting patients to community providers, PBC and other referral management systems may put specialist services at risk.

Quality of care

And what about research that suggests that incentivising GPs to change their referral behaviour risks reduces the quality of patient care?

Professor Martin Roland, professor of general practice at the NPCRDC and a GP in Manchester, admits this is ‘a tough question'.‘If the aim of any referral management system is to offer incentives to simply reduce referrals by refusing them without judging their appropriateness, that could harm patient care,' he says. ‘Anything that involves a quota also could, because there's no relationship between high rates of referral and poorer patient outcomes.'

Professor Elwyn says referral management systems were borne out of a ‘policy clash'.

‘It might seem strange that healthcare policy has gone down this road. But then, referral management systems have never been supported from the top. They were brought in when the Government was pushing for policies such as Choose and Book, and PCTs were left to find a way of managing the chaos.'

His evaluation suggests GPs will need to find a way to get to grips with referral management systems, as part of a brave new world of primary care.

‘The underlying ethos and the motivation – that there exists a considerable volume of referrals that need to be handled in more efficient and cost-effective means – remains valid. The concept of "managing" such referrals has not gone away and is likely to be a recurring theme over the next decade.'

Waiting room How managers are keeping referrers in check How managers are keeping referrers in check

Referral management centres

These are usually telephone triage systems, computer-based decision support systems or clinicians appointed by the PCT to assess referral criteria on a variety of clinical grounds. Centres refer appropriate cases to specialists and bounce inappropriate referrals back to primary care to be managed by their GP.

Practice-based commissioning

Each practice or consortium produces a report on an individual GP's referral behaviour, and compares it with that of colleagues, as well as PCT and national averages. Outliers, either high or low referrers, are investigated to identify patients who are appropriate for management in primary care.
Profits can be substantial, and some claim community care can be up to 80% cheaper than the same service provided in secondary care. How much profit is retained by the practice or consortium can vary.

Choose and Book

Can be used to manage demand by highlighting other service or hospitals, and can in some cases restrict the ability to refer.

Dr Mike Dixon Dr Mike Dixon

With PBC, GPs compare the referral data and identify the high and low referrers.

Professor Martin Roland Professor Martin Roland

If the aim is to cut referrals by reusing them, that could harm patient care.

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