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How to cut referrals without harming patient care

Dr Lucy Wictome explains how her practice conducts daily review meetings to assess referrals, get specialist opinion and find ways of treating patients in general practice

GPs, myself included, remain daunted about what the white paper and practice-level commissioning responsibilities will mean for our day-to-day work. The white paper sets out to liberate clinicians to innovate – but what can we do now?

The reality is that every GP in every GP consultation already potentially acts as a commissioner if they choose to make a referral. Whichever consortium an individual GP practice joins, it is likely practices will be asked to review referrals and reduce inappropriate hospital use. We are all acutely aware that a referral commits a resource, and every time we make one, we are spending the taxpayers' purse.

Reviewing our referrals should align clinical and financial accountability. But we are all busy practices, so how can this be achieved?

Set a time and stick to it

I would encourage practices to set up regular clinical review meetings, either daily as in our practice, or weekly. We are

a training practice and consist of four GP partners, one salaried GP, an ST3 and ST2 GP trainee, an F2 doctor and three practice nurses. When I joined back in 2001, daily clinical review meetings were already well established, stimulated by fundholding, when practices were first held accountable for the NHS money they spent.

Initially, meetings were ad hoc, but soon we realised the benefits of a training practice having a forum for reflection on referrals and an interface for discussion of clinical mail. The clinical meetings then became formalised – as like most things, if left loose we found things would slip.

So a daily slot was agreed at 12:45pm for a maximum 30-minute review meeting. There was a collective agreement with the practice manager, administration staff and clinicians that this is a vital part of the working day to be protected, with participants only disturbed in an emergency. It focuses us to manage our time efficiently, be back from house calls in time or crack on with reports.

Use the skills of all the team

The main part of the meeting covers formal case reviews, including any referrals clinicians have made or potential referrals they are thinking of making. This enables all those present to contribute to an individual patient's management plan and often highlights possible interventions or investigations that mean a referral may not be necessary.

Established GPs give their experience and trainees are a very useful resource, able to feed back to those of us who last did hospital jobs many years previously about current practices and procedures, helping to answer questions such as ‘Why did they do that? We didn't do that in my day!'.

Our district nurse colleagues, health visitor, midwife, community mental health team and community matron are invited along when issues arise and are welcome to bring up specific cases or areas of concern.

Review referral outcomes

We sometimes review particular aspects of our referral based either on the demands of our PCT or on collaborative work with local groups that we are part of, such as the Wallasey Health Alliance. Most recently, all the local practices that are part of the group looked specifically at their trauma and orthopaedic referrals, as there was a move to try and reduce them. On the most recent review of three months of activity of referrals for trauma and orthopaedics, all referrals were deemed appropriate, as every one of the patients we sent to hospital had some form of surgical intervention.

Identify cases that can be managed in the practice

A recent example in our practice was of a patient suffering with benign paroxysmal positional vertigo that the partner felt would benefit from a referral to an ENT clinic for review and possible Hallpike's manoeuvre. It became apparent the ST2 GP trainee had spent many years training as a specialist registrar in ENT and happily saw the patient, doing the manoeuvre, which completely settled all the symptoms.

Update yourself on the latest clinical developments

Issues arising from the day's clinical mail are highlighted and appropriate actions taken. Sometimes this leads to discussions about new drugs or technology that crop up in discharge information, which may prompt someone to review journals such as the BMJ or British Journal of General Practice and present back to clinicians at a later meeting. New diagnoses of cancer and mortality reviews are also done in these meetings, when the clinician responsible for the patient looks back at their clinical management.

Invite specialists in to share their expertise

When an area is identified we need to explore more fully, we may invite a speaker in to talk to us. Recently we had an informed debate about heel pain and plantar fasciitis – having reviewed journals we found arguments for and against performing cortisone injections.

So having identified the need, we invited a local orthopaedic consultant who specialised in foot problems to come along. He told us about possible examination techniques to decide on the differential diagnosis, explained scenarios that might need investigation and concluded with treatment options. We all feel this has lead to improved care and fewer referrals.

Over the past 12 months we have had many other guests, including a consultant nephrologist to discuss chronic kidney disease, a respiratory consultant to discuss advances in COPD treatment, a consultant cardiologist who discussed advances in treatment of angina, and a consultant endocrinologist who discussed optimising diabetes treatment in primary care, especially insulin initiation.

We are awaiting a consultant vascular surgeon who is going to discuss indications for varicose-vein surgery, as recently a patient was deemed inappropriate according to local NHS guidelines and it wasn't clear why, so this was flagged up on the clinical mail as an area of learning need.

Record the discussions for your appraisal

Since 1 April, 2004, when GPs were contractually obliged to participate in an appraisal process, clinical meetings have been formally recorded on a daily basis using a simple form that captures attendees and items discussed, and is then scanned onto the practice computer.

The process has consistently been identified as an important part of both the practice development plan and individual GP's personal development plans.

Dr Lucy Wictome is a GP partner at the St Hilary Brow Group Practice in Wallasey, Merseyside

Take-Home Points

1. Decide whether a meeting daily, a couple of times a week or weekly suits your practice.

2. Set a time, stick to it and start on time – 30 minutes maximum if it's daily. If it finishes early that's fine.

3. Gain collective agreement from the practice manager and administrative staff that this time will be protected – except of course for emergencies.

4. Encourage full participation from all clinicians, whether they be the senior partner, trainee doctor or nursing staff – you can all learn from each other.

5. Use the time effectively for case reviews, clinical mail issues, mortality reviews, journal reviews and – if a collective area of need is identified – consider inviting along a guest speaker.

6. Design a simple form to complete on a daily basis to record items discussed and have these stored on the practice IT system for appraisal.

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