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Referral management ramps up costs but fails to reduce outpatient attendances, find researchers

Referral management schemes fail to cut down outpatient attendances and incur significant costs, a UK study has revealed.  

The three-year study, from April 2009 to March 2012 and published in the British Journal of General Practice, showed that referral management services – such as referral management centres and internal peer review of referrals – failed to reduce outpatient attendance rates and, in one case, actually increased rates.

The study of 85 practices in Norfolk cast doubt on whether the use of referral management services is likely to offer value for money, despite recently being promoted by NHS England, at a time when many CCGs are looking to such services in a bid to cut referrals and hit budget targets.

Researchers reviewed one set of practices that used referral management centres and another set of practices that used internal peer review to manage referrals, involving monthly peer review and feedback to GPs, to see what impact they had on outpatient referral rates.

Results showed that none of the approaches led to significant changes in outpatient attendance rates. On the contrary, one group – which used the referral management service with the largest budget and widest range of activities – had a significant increase of 1.05 attendances per 1,000 patients per month.


The study also found that the costs of running the schemes averaged £0.97 for internal peer review and £5.18 for referral management centres per registered patient in the year 2011/12.

The authors concluded: ‘The lack of effect found by this study suggests that a cautious approach should be taken to adopting referral management, particularly if undertaking a wide range of activities across multiple specialties.

‘Given the widespread use of referral management, evaluation is needed to understand the relative importance of each component in referral-management interventions, if referral management is to be applied effectively to reduce outpatient attendances.’

Dr Chaand Nagpaul, GPC negotiator and a GP in Harrow, said: ‘It really does demonstrate that CCGs need to be careful not to go with gut feelings on how to reduce referrals. In particular, there is no evidence that introducing referral management centres is actually successful in reducing referrals and it adds considerable costs by adding a bureaucratic tier into the process, as well as diminishing the sensitivity of the relationship between the patient and referring doctor.’

Dr Nagpaul added: ‘We need to empower GPs to make appropriate referral decisions rather than have a third-party tier that restricts referrals.’

Dr Helena McKeown, GPC member and a GP in Salisbury, said: ‘What can be useful is discussing referrals that are not cut and dry with colleagues and seeing how you might be able to do things differently, but I’m not a believer in referral management centres.’

She added: ‘What is the point of them if they are increasing costs? Review of referrals can be looked at in-house, or with a few practices getting together – we don’t need managers to scrutinise the quality of referrals.’

Br J Gen Pr 2013; 63: e386-e392