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Can CCGs rise to the referrals challenge?

GP referrals look to be on the rise, raising early question marks over CCG performance. We asked our expert panel what CCGs can do to stem the referral tide


JK: Dr James Kingsland

NW: Dr Nigel Watson

MD: Dr Michael Dixon

KO: Professor Kate O’Donnell

CO: Christine O’Connor


Why do you think GP referrals have increased this year*?

JK I’ve not seen the data, so its always difficult to say if it’s a snapshot or a trend.

You can always speculate that referrals go up at a time of change, but I think that’s secondary to what we do about it. This is

the core of what the reforms aim to do, which is to get primary care to step up to

the plate.

Making more and buying less from secondary care is key. Some people would say that cutting referrals equates with good practice, and I accept that up to a point. But the whole principle of the NHS as a gold standard worldwide is based on appropriate referrals by GPs.

NW Patients are getting older and there are more people with long-term conditions. In addition, there’s patient expectation – society is more demanding. There is a consumer culture that drives up demand. Plus, there is a lack of options in terms of managing patients.

As a result, GPs are under huge pressure – so this is not unexpected.

MD I’d question whether there has been an increase at all. In lots of parts of the country, referrals are actually going down. In Corby, they’re going down. In my area, Devon, they’re going down.

There will be variations, but one does wonder where they are going up.

KO The question is whether or not it’s a real increase. You do get fluctuation on a year-on-year basis.

CO The reasons are a lack of willingness to take ownership for managing in an alternative way, lack of understanding of what to do and no alternative model for the second-opinion concept.

*Department of Health hospital activity data (up to and including May 2012). GP referrals made this year, on a year-to-date basis, show a 9.6 increase compared with the same period last year.

Does this referral ‘rise’ mean CCGs are already off to a rocky start?

MD Where rates are going down, it’s certainly to do with the impact of CCGs. Where referral rates are going up, it’s probably because CCGs are not yet attending to them because they are focusing on other things.

KO Not necessarily. Politicians and policy makers need to unpick the areas of referrals that are patient- or system-driven. These are areas that tend to get glossed over.

Also, with CCGs currently focusing on authorisation and governance issues, referrals might be an area that has less traction in terms of their attention.

CO Not really. The danger for CCGs is that they are doing what PCTs have done in the past, and in their effort to get ‘early wins’ they are focusing on tactical, low-impact solutions instead of strategic, big-ticket items.

This is a transformation agenda, not a transactional one.

NW No. We need to look at and address the problems I’ve outlined above.

JK I think it’s indicative of the enormous task CCGs have to do. In UK general practice, the expertise is having a wide range of knowledge, a wide-ranging team, 21st century premises and diagnostics so that you are able to connect all episodes into one finished episode of care. And in that respect, these reforms are really about the reform of primary care provision – not just of primary care commissioning.

Is there a danger CCGs can become too focused on getting referrals down?

KO This is the real danger.

My work suggests we don’t know enough about what constitutes the right level of referrals, and we’ve seen from waiting times and access targets in primary care that attention can get focused on things that don’t necessarily improve the patient experience.

Referrals are easy to measure so a light is always going to be shone on them. The danger is in a blind allegiance to getting everything down to a ‘mean’ when nobody knows whether that is an appropriate level or not.

MD This is definitely a danger, because you can only knock the fat off the animal to a certain extent.

We found with tackling prescribing that there were lots of savings in the first year, then it did tend to tail off. The other danger of looking too much at referrals is that you lose focus on redesign. I would say the two have to go hand in hand.

CO Absolutely – this is not about getting referrals down. It is about enabling referrals to be dealt with in the most appropriate way. I still do not think CCGs have truly recognised what their job is and essentially that is to re-engineer general practice and drive up standards.

NW Yes. CCGs need to work with practices to develop effective pathways and focus on registered populations.

JK Just focusing on getting referrals down leads to inappropriate emphasis on things like referral management schemes.

Do we know what the quality of GP referrals is like in terms of efficiency and appropriateness?

NW No. Most comments are just anecdotal.

KO We found patient characteristics explained up to 40% of the observed variation in referrals rates, while practice and GP characteristics explained up to 10%. The rest was much less easy to explain.

JK I think we have to get away from the primary and secondary care distinction.

It’s all about pathways. Years ago, I had to admit a patient if I wanted them to have a new ACE inhibitor. But that was 25 years ago and now it would be completely inappropriate. There’s a shifting interface.

Our basic training as a GP is as a diagnostician. We need to have the sharpest minds in general practice because it’s where patients first consult, and GPs can pick things up at an early stage.

CO Probably only at a CCG level if the CCG is looking at referrals in a meaningful way.

There is ‘cover your back’ referring and ‘giving in to patient demand’ referring. Are these big issues for CCGs to overcome?

JK These are very real issues that could become a problem if they are not recognised. It’s a bit of a slippery slope. However, the reforms are legislation to change behaviour.

If we want different outcomes, such as patients spending less time in hospital and greater accountability, what’s absolutely key is for CCGs to change the culture.

MD This is quite a big issue, especially among younger clinicians. We plotted it in our practice and it’s almost a straight line.

There are some generational attitudes that play a part. An old fogey like me tends not be so worried about defensive medicine, whereas younger partners don’t want to mess up their career and are literally terrified in a way I don’t remember us being.

The role for CCGs is to make sure there is enough headroom for clinicians to look at referrals, providing data but also crucial support.

CO It probably varies from practice to practice, but GPs need to be trained in negotiating skills to improve their ability to say ‘no’.

NW Such issues are big and growing for CCGs. However, relatively speaking, these are not the greatest cost pressures for the NHS.

KO I’m not a clinician, but I guess it must happen. Different GPs have different levels of tolerance of risk and some will be more defensive than others.

My experience on the whole is that GPs tend to manage a lot in primary care. GPs referring defensively tend to be a small proportion.

Is there a place for referral management schemes under CCGs?

CO Yes, but it needs to be done in a proactive, value-based and engaging way, not a top-down dictatorship.

It’s about the process of engagement and the way it is introduced. It should not be a stick approach, but about educating for changed working practice.

NW As long as they are supported by the GPs and not used as a blocking mechanism. The reason some work and others don’t is all down to clinical engagement.

Good schemes can increase communication and improve skills. But it all takes time, and primary care is losing capacity.

JK Some may be necessary at the moment. And where they are helping to ensure early diagnosis and more reflective practice, in the short term, they are good. But the idea of referral management schemes as an innovative way of delivering care is a non-starter.

If we celebrate referral management as a great system, then we’re falling into the trap of investing in failure.

KO It depends on the area and types of referrals. We did our original work on referrals variation because our health board was considering introducing referral management. I was always a bit concerned that such schemes are about simply reducing referrals rather than going into the detail.

Whether they work or not has to do with the importance of a good, long-term relationship between management and practices. It makes things much more likely to work. My conjecture would be that where referral management works better it is because of a better relationship between CCGs and practices.

MD Yes – providing they are thoroughly owned by CCGs. Those that don’t have a place are schemes that are imposed from above.

I think they should have a place in every well-run CCG and should be renamed referrals support schemes. Every CCG should have one.