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GP consortiums set to ramp up referral management schemes



By Ian Quinn

Up to a third of GPs’ referrals face being rejected by their local commissioning consortium in the ‘Arctic’ financial conditions predicted for the NHS, according to a new report by the King’s Fund.

The influential think tank predicts many consortiums will establish tight peer-to-peer controls over individual practice’s referrals, which could mean GPs having every decision to refer having to be approved by their consortium leaders.

It comes after Pulse exclusively revealed that the Government is planning to tie practices pay to their effectiveness in bringing down hospital referral rates.

However, the King’s Fund report warns that if GP consortium leaders interfere too much with GP decisions, it could cost more than it saves and pose ‘a real risk’ to patient safety.

‘GP commissioning consortia are about to enter into a cold, potentially arctic financial climate,’ says lead researcher Candace Imison, deputy director of policy at the King’s Fund.

‘The need to control demand will be overwhelming and many, if not all, might turn to referral management as a means of doing that.’

Primary care tsar, Dr David Colin-Thome, told Pulse this week that GP contracts would be re-written to ‘reward them for how much they can benefit from being more efficient providers of care in, say, making less inappropriate use of hospital services.’

The King’s Fund report – including detailed interviews with more than 20 trusts – says research points to up to a third of referrals being not clinically necessary, including 23% of referrals to orthopaedics and 37% of non-urgent cancer referrals.

‘A substantial proportion of activity is discretionary and avoidable,’ it claims, adding that a ‘large number of patients currently referred to secondary care could be seen in alternative settings.’

However, the report found the most extreme PCT referral management schemes had failed to tackle the boom in referrals, were not cost effective and had in some cases led to patients not getting the right treatment.

It warns that if GP commissioning consortiums try to drive blanket reductions in referrals rates ‘there is a risk of it leading to a reduction in necessary as well as unnecessary referrals.’

Referral management has also widely ignored the quality of referrals, finds the report, with out six of the 20 PCTs saying they had used them in a bid to improve the quality of referrals and only five believing they had achieved it.

‘The analysis suggests that the greater the degree of intervention, the greater the likelihood that the referral management approach does not represent value for money.’

‘A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referrals criteria and evidence-based guidelines is most likely to be both cost effective and clinically effective.

‘Missed or late referral can prolong suffering and worsen outcomes. Any referral management scheme should claim to uncover missed referrals as well as stopping inappropriate ones,’ say the report.

‘Yet the context in which referral management is frequently introduced is one of financial constraint and the focus tends to be on managing demand rather than improving quality. Given the future financial prospects for the NHS, this present a real risk to safe clinical care if unchecked.’

GP consortiums set to ramp up referral management schemes