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How peer review reduced referrals and raised quality

Getting GPs to sit down and discuss their referrals has cut rates by 9% and improved referral quality. Nene Commissioning's Dr Darin Seiger and Sally Picken explain.

Referral rates are on the rise – but our PBC group has developed a scheme that is bucking the trend. Between January 2008 and September 2008 there was an 11% increase in national referral rates, and a similar rise in Northamptonshire of 10%. By taking clinical control of the issue through GP peer review, in just six months Nene Commissioning PBC group saw elective GP referrals to the region's two main hospitals drop by 9% and 12%, compared with a national rise of 13%.

Nene Commissioning's ability to make things happen is helped by the strong relationship we have with our PCT, NHS Northamptonshire, and the scale of our organisation. The largest PBC group in the country, Nene Commissioning is a community interest not-for-profit organisation that has 76 practices covering 660,000 patients. The area covered by the group is divided into four localities, each of which has a GP commissioning lead who sits on the Nene Commissioning board so any issues can be discussed directly with locality representatives.

In spring 2008, the PCT said it needed to reduce referral rates and wanted to explore the possibility of a referral management centre that would screen all referrals to ensure they were appropriate. Nene Commissioning members rejected that model on the basis that it wouldn't help the patient, as the consultation would have already taken place and a management plan had been agreed. Rather than having to meet an arbitrary reduction target, GPs wanted to focus on improving their quality of referrals.

Focus on letters

GPs felt the way forward was to try to understand referral variations within the same surgery and between practices. This would involve looking at GP referral letters retrospectively and comparing with the outpatient discharge letters. GPs would then examine what the actual diagnosis and outcome of the referral letter was, and whether the patient could have been managed differently. So if a patient with knee pain was referred by the GP to an orthopaedic clinic, the outcome might be that an operation wasn't necessary and

that the patient required physiotherapy. Had the GP referred for such treatment directly they would not only have saved on referral costs, but have also ensured a better outcome for the patient. Making this process work would require open and honest feedback from GPs, and a system designed to ensure information would be gathered and used in the most effective way. Representatives from the Nene Commissioning Board talked to NHS Northamptonshire and persuaded them to agree to a six-month peer review pilot.

GP buy-in

Locality leads spread the word about the proposal. Nene Commissioning then sent each practice lead partner a declaration form to sign to confirm they were happy to take part in the pilot and to agree to submitting peer review forms from their practice to the PBC group on a monthly basis.

To encourage clinicians to buy in to the scheme it was important to reassure them that it was not designed to single out and condemn practices where referral rates were particularly high or low. Practices have different referral rates for different specialties, and whatever their level, nobody should feel victimised. Discussions, we stressed, would avoid labels like ‘good' or ‘bad', ‘high achieving' or ‘poor achieving'. Instead they would focus on sharing ideas and fostering good practice so that variations could be explained in a constructive manner. By providing this reassurance the majority of practice members – 69 out of an original 75 – initially signed up to the scheme.


It took just six weeks to get the scheme off the ground. Practices receive £1 per patient per annum on their list in recognition of the time involved, which is funded out of our freed-up resources. Each month, practices focus on a specialty, looking at individual referral letters, then the outpatient letters (see box, top right). Clinicians talk about the outcomes as a group, debating reasons for a high referral rate and whether there were any other pathways patients could have followed. For example, some GPs may not be aware that there are direct access pathways for certain diagnostic tests such as MRI for tinnitus, or that newly commissioned community services exist such as minor surgery for basal cell carcinomas.


The data discussed by practices is produced by a full-time analyst, Anne Holland, who is employed by the PBC group. Anne takes her information from such sources as Hospital Episode Statistics, Choose and Book data, Dr Foster information and budget monitoring data from the PCT. We learned early on that we shouldn't focus too much on the fine detail but look at trends – otherwise people can feel bogged down by information. One of the most useful ways of presenting information to GPs was in the form of a bar chart. The chart shows the referral rate per 1,000 people for each practice within a locality along the vertical axis, and the PCT and locality average on the horizontal axis, so GPs can easily identify how they rate. To see a bar chart click here.

Practices concentrate on improving the referral quality of our top five specialties: gynaecology, orthopaedics, dermatology, ENT and urology. These disciplines have the highest volume of referrals and are areas where GPs can have the most influence in terms of reducing secondary care visits.

Practices must fill in a monthly report on outcomes from their peer review meeting, which is sent to the PBC group for analysis.

Enhancing education

The opportunities for GPs to develop their skills through this scheme are enormous. Each practice has the chance to take part in a half-day protected learning time session to further GP education. Although practices must finance out-of-hours cover in order to attend, Nene Commissioning has allocated up to £27,000 a year to fund extras such as payment for trainers. For example, some practices wanted more education on dermatology, so the PBC group has used FURs to fund dermatoscope training. Other practices have been learning joint injection techniques.

Tackling pathways

The PBC group has also come up with various ways to speed up care pathways. For example, using FURs it has given practices with an interest in dermatology funding to purchase dermatoscopes, allowing GPs to magnify lesions and differentiate whether they are malignant or benign, rather than having to involve a dermatologist. The GP peer referral review scheme identified that gynaecology rates in one area were quite high. Nene Commissioning shortened the care pathway to allow GPs to refer patients directly for a pelvic ultrasound rather than via a consultant. Six months later, gynaecological referrals had been reduced by 22%.

Prior to introducing the peer review initiative, referrals across the four localities varied from 8.25 to 11.75 per 1,000 patients. Now they range from 7.5 to 8.5 per 1,000. If attendance rates for 2008 had been maintained in 2009, a modest measure of savings in the first year is in excess of £600,000. (To read Nenes report click here.) Following these results, the PCT approved the scheme and it was formally launched in June 2009. Some 96% of practices are now signed up.


Those looking to set up a peer review initiative should be flexible in terms of specialties covered throughout the year, so they can be responsive to GPs' developing individual interests. It is also essential to have actual referral letters to examine at practice level review meetings. This enables GP peers to challenge and learn from each other – and if the discharge outcome of the referral letters is alongside it, even better.

Data should be presented to clinicians in a simple and transparent way that they find meaningful. It's important not to get swamped by data as some will be inaccurate or incomplete. All data is only a pointer to where improvements need to be made – we can learn as much from GP group discussions as from practice feedback forms.

The main focus should be getting GPs together to drive up the quality of referrals. In doing so, practitioners have the chance to discuss issues about daily practice and to take part in multidisciplinary learning – something often missing from their daily working lives. All of which makes peer review an extremely powerful tool in primary care.

Dr Darin Seiger is a GP in Northampton and chair of Nene Commissioning. Sally Picken is a service development manager for Nene Commissioning.

Getting the most from the practice meeting

1. Send out letters to be reviewed ahead of time. ‘Buddy up' partners so one partner looks at the referrals of another. Rotate buddies each month.

2. Singlehanded practitioners can ‘buddy' with clinicians from another practice to check a referral is appropriate.

3. Have a joint meeting for practices that share premises, as data is often skewed between these practices because of
coding issues, and is more useful at a joint level.

4. Practices reported it useful to look at a range of three to 10 letters per clinician. Looking at actual letters is more important than the number reviewed. The more that are considered, the less time can be spent on each one, so practices should strike a balance that works best for them.

5. Ensure you have sufficient time for the review and that everyone is clear about its purpose and the desired outcome.

6. Don't get bogged down in the locality data – remember this highlights variations and issues for discussion at practice level. Use it as a context to understand the relative overall level of referrals for the practice.

7. Set up systems to prospectively identify relevant referrals for future review rather than trawling for referrals after the event. Staff at some practices keep a folder of all the referral letters by the speciality to which they have been referred.

8. Ask a partner with specialist knowledge to review referrals within that area.

9. Where possible, review the outcome of referrals alongside the original referral letters.

Source: Nene Commissioning

Referrals chart Nene Commissioning report 60 second summary

Initiative: Inter- and intra-practice peer review scheme to improve the quality of GP referrals

Start-up costs: £1 per patient per annum to pay for GP time attending monthly referral meetings

Preparation time: Six weeks from initial idea to launch of the scheme

Staffing: Data analyst, administrative support

Results: After six-month pilot, elective GP referrals to the region's two main hospitals dropped by 9% and 12%, compared with a national rise of 13%

Savings: In six months, 900 outpatient referrals to orthopaedics were prevented at a saving of about £135 per appointment. More than £600,000 saved across five specialties in the first year.

Contact: Sally Picken, service development manager, Nene Commissioning,