Referral gateways have come under criticism for their rushed implementation, poor infrastructure, lack of clinical ownership and having little benefit to the practices or commissioners concerned.
Two years ago, The King's Fund1 reviewed the many approaches to referral management and clearly identified that ‘commissioning consortia are about to enter into a cold, potentially arctic, financial climate. The need to control demand will be overwhelming'.
Looking back to 2008 when budgets were plentiful, hospitals in Manchester were managing demand well, with ample resources at their disposal. But with a growing population across the three CCGs (North, Central and South) of more than 500,000 people served by four large acute trusts – three of which have foundation status with referrals of over 180,000 a year – clinical commissioners knew referrals needed to be better managed.
In addition, we had a seven-year integrated care and treatment service contract costing £7m a year based in the acute trusts, designed to help achieve the
18-week wait targets – which was being drastically underused, but for which we were paying for regardless.
A range of community and Tier 2 services, along with 140 different referral forms, made for a complex, confusing system for those in primary care.
A slow build-up
Three years ago, we began to address referrals by looking in more detail at hospital secondary uses service (SUS) data, which showed numbers of referrals were on the rise.
Initially, we worked as a clinical community on an incentive scheme based on peer review of referrals, which we believed would solve the problem.
But while we identified learning opportunities, it seemed to do little to actually change referral behaviour. The main problem was the data was always two to three months out of date.
After discussions between the three PBC groups as they were then, it was decided that South Manchester PBC would run an initial six-month referral gateway pilot in four practices with two senior GPs triaging referrals and a central booking team managing data flow and the Choose and Book function. This proved successful enough to prompt clinical commissioners to widen the project across Manchester.
A business case for a city-wide referral gateway, developed by the PBC groups, was approved by the PCT's executive board in February 2010.
Knowing the plans may prove controversial, the PBC groups worked hard to continually raise the issue at local GP meetings, in their local newsletters and with the local LMC between the sign-off and go-live date in September that same year.
In 2010/11, each PBC group practice voted on using part of the local incentive scheme funding to help pay for the gateway.
After a group event to determine the approach that should be taken, key themes emerged – such as the need to create a standard referral template to simplify the process as much as possible. There was also much debate on how to give advice back to referring GPs, who should do the triage and how governance for the system would work.
We approached the LMC twice with the plans, which were first rejected. But after going back to the drawing board and making some changes, it agreed to the proposals.
The LMC was very keen to improve the quality of referrals, but like many others it was not convinced the scheme would cut referrals massively or save any money. It also felt very strongly that this could not be mandated and GPs should be free to make direct referrals if they chose to do so.
The eventual model
Given the need to be as paperless as we could be, we decided to commission a one-year, £1.2m pilot of a referral management centre for all Manchester GP practices. A provider was brought in to support the IT system and our out-of-hours provider managed the triage process.
The result of the many local discussions was one standard referral template and one standard HSC205 template for cancer referrals, which self-populates from each of the practice's clinical systems.
This was emailed to a secure NHS net address, where the referral management centre/triage team first checked that the minimum data required was all in place – such as the patient's date of birth and NHS number – and then that the referral was not for a non-commissioned procedure such as varicose veins, which are not funded in Manchester unless clinically appropriate, or tonsillectomy, which has strict criteria before it should be considered.
If all the basic information was correct, the referral was clinically assessed by one of a team of GP triagers – who logged into the system remotely – and allocated to the most appropriate care pathway.
Referrals could be returned, within 48 hours, with advice and guidance to support the practice to manage the patients in primary care. The referral management centre notified practices of all their referrals via email, and sent them weekly reports outlining the status of each referred patient, by clinician, allowing them to reflect on performance.
Visibly striking results
Over the 18-month pilot period there was a 12-15% reduction in outpatient referrals, a drop of 3% in elective or day-case activity (see graph above) and an increase in ICATS usage from 42% to 79%.
In total, the referral gateway pilot produced an estimated cost saving of £4-6m based on prevention of non-commissioned procedures and deflections to alternative providers.
In addition, the three GPSIs in cardiology who worked as triagers put together a business case for a Tier 2, city-wide cardiology service after identifying a gap in provision between routine primary care and specialist hospital services.
There are plans for other similar services, including one in neurology, and through these additional services we have generated income for primary care.
But the major benefit, we feel, has been to improve the overall standard of general practice referrals in Manchester. This improves the quality of care patients receive and is something for which as CCGs we will be accountable to the NHS Commissioning Board.
We are now in a good position to have constructive relationships with our acute colleagues around pathway redesign.
Referral gateways are very controversial, and at first there was resistance to the plans.
Concerns from primary care included the validity of someone else making a final decision on a referral when the GP was best placed to know what the patient needed and the potential for added bureaucracy.
With the exception of one or two practices, the vast majority of GPs from the 103 practices in Manchester now use the gateway and there are a number of factors we believe have led to this almost universal acceptance.
The first is that this was not something introduced suddenly and on a whim. It was developed over a long period of time and after plenty of discussion and collaboration with primary care through local meetings, the CCGs and the LMC. We showed GPs it would be effective through the smaller pilot at the beginning.
One very important factor in setting up the gateway was the use of local GPSIs and senior, well-known GPs. It meant the other GPs respected the decisions made and the feedback they were receiving.
Because the advice is provided in a very professional and supported way, the GPs saw it as more of a CPD tool than criticism of their decisions.
We also made it as easy as possible for GPs to use, and made sure the patient still had a choice in where to be seen.
There was a gap between the end of the pilot and further rollout, and our data showed over that period referrals shot up again – which proved we needed to be in this for the long haul.
One aspect that was not one of the main aims of the scheme, but will prove vital in the future work of the CCGs, is the building of relationships between primary and secondary care. The hospitals did not believe we could affect referrals because the PCT had promised many times to ease their pressure and had failed to do so.
They were very sceptical, but now their case mix is quite different and they can concentrate on the complex work they are trained to do.
Better working relationships between primary and secondary care have also enabled us to open necessary discussions about pathway redesign.
One of the reasons we needed this in the first place was because primary and secondary care had no working relationship. Doctors had lost the ability to ring up a consultant to get advice on a patient or referral. Now, clinicians and managers sit down once a month and talk about how to improve services – something that simply did not happen before.
From April this year we have been running the project in-house – a move we took to reduce costs and protect the local workforce.
We have sourced a software supplier to implement the web-based system it has developed to streamline the process of submitting referrals.
Through this system, a GP can complete a referral form for a patient that is then automatically loaded into our central database for assessment.
And using web-based access, GPs can review progress details of individual referrals, view the status of all their referrals and view a summary of referral status for their surgery in real time.
A new business intelligence dashboard enables GPs to review and monitor their own referrals, to review and monitor referrals made from other GPs in their practice and see how their referrals compare with referrals made by other practices in their area.
Moving forward, we plan to bring SUS data validation into the software as well as budget monitoring information. Cost control will enable us to undertake more referral data capture, such as in obstetrics and mental health.
We think this approach will have an even greater impact on referrals from a service that costs £700,000 a year and now has more than 30 senior GPs involved in triage.
Strategically, this will help CCGs improve the quality of primary care by giving real-time advice and guidance
back on referrals made, keep a grip on elective activity and strengthen our management of patients with long-term conditions.
A long-term aim of all three CCGs is to reduce demand on our hospital services and assist us in delivering QIPP, and this project ticks all the right boxes.
Simon Wootton is interim chief operating officer and Dr Martin Whiting is interim clinical accountable officer at North Manchester CCG
Top Tips for implementing a Referral Gateway
- • Clinical engagement is vital – drip drip is better than big bang
- • Identify your advocates – CCG and LMC members are very powerful
- • Clinical ownership and stewardship of the project are key
- • Good project management skills for support are important
- • Use local, respected, specialist GPs to triage
- • Make it as electronic as you can to ease paper shuffling
- • Find out the things that cause problems in referrals – such as templates and Choose and Book – and try to eliminate them
- • Accept that not all will be believers, but keep working until everyone is on board
- • Provide quality advice and guidance to practices on referrals
- • Keep your providers informed – they often doubt commissioners can do things