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How peer visits helped get referrals under control

Dr Neil Kerfoot and Dr Briony Lodge of South Gloucestershire pathfinder consortium explain how their innovative peer review is getting all practices on the same page as the exec.

Two years ago – like the rest of the country – referrals in South Gloucester were on the up.

We faced an extreme challenge not to create a deficit and, with increasing elective care and outpatient rates, were in danger of going into the red. Something had to be done and our approach was to encourage GPs to share and exchange knowledge on referrals to make them more effective.

By supplying clear information, encouraging peer review within practices and arranging annual visits to practices by the exec team, we have started to see good results. Our latest year-to-date figures reported a 3.35% decrease in referrals for the same period last year.

Engaging practices

As GPs we not only have to decide whether to refer or not, but also how to ensure the referral itself is effective so the patient is seen by the right person at the right time.

Until now, the norm has been for these decisions to be taken by GPs unilaterally within their consulting room. We believed that by getting GPs to discuss their referrals with their peers and making them aware of how their referrals compared with others, we could make referrals more effective.

Getting practices engaged with what we were doing was crucial, and a key factor in getting GPs on board was our overarching commissioning plan. We spent at least six months working on this when three local consortia merged into a single one, co-terminus with the PCT and local authority, in 2008.

By 2009 our commissioning plan was ready, with referrals identified as one of our main objectives. We asked all practices to sign up to the plan and to identify a named lead to ensure the objectives were worked towards within the individual practices.

Each practice received some £5,000 to pay for things like locum cover to free up the practice leads to work on the consortium’s agenda. In return for the payment we asked each practice to have a monthly meeting with partners and practice managers on their referrals and to feed back their findings to the consortium.

The exec might suggest practices look at a particular disease area at their next meeting and we encourage them to qualitatively examine individual referrals and what the eventual outcome was once the patient was seen by the consultant.

The monthly meetings have prompted exchanges between GPs on how to refer.

For example, some GPs are uncomfortable performing trigger finger injections and in the past may have referred to orthopaedics. But now, if they know a colleague is happy doing them they will ask the patient to rebook an appointment at the practice.

Also, in some cases, it might be more effective to refer to a health professional other than a consultant. The obvious example is a physiotherapist, rather than referring straight to orthopaedics. It helps to share knowledge with GPs about which patients were seen by orthopaedics and referred onto physiotherapy.

It has also been useful for making simple changes to pathways. As GPs look closer at what happens to patients after referral, it has become apparent the consultant might always ask for a certain test to be done. GPs are now starting to order the test when they make the referral, which speeds up the pathway for patients and possibly avoids an additional outpatient appointment.

Practices’ innovations to make referrals more effective are fed back to the consortium and we share these ideas in our regular newsletters. The annual visit (see below) by the exec team to each practice was included in the commissioning plan that all 27 practices signed up to.

Data sharing

To facilitate the monthly meetings we distribute regular data showing how practices compare with others and this is presented in graph form, compiled by our commissioning group’s project manager Beverly Stretton-Brown. (To see sample data, view this article online at

We provide, on a monthly basis, practices’ elective, non-elective and A&E attendances.

Beverly has developed the data format over the past two years to allow practices not only to compare themselves with their neighbours, but also how they’re doing compared with the same period last year.

Before the annual meeting by the exec, practices will receive more detailed data about their performance and whether they are on track with the consortium’s objectives.

In the past year, we’ve also commissioned some alternative pathways such as a DVT service provided by a GP provider company and a new community IV antibiotic service, and persuaded the acute trusts to introduce ‘hot clinics’ so patients can be seen in the next day or two by a consultant rather than having to be admitted. So before an annual visit, practices are advised how much use they have made of these services.

Practice visits

The annual practice visits take up to two hours and are done by two exec GPs and a practice manager. The three meet with the GP who is the practice lead for commissioning, the practice manager and any other GPs who are available, depending on workload.

Using the data, we discuss how they’re performing and if we are on track with the consortium’s aims. The visits allow practices to ask questions and for the exec to learn about what practices are doing on the ground and the aids and barriers they face in improving performance. If we feel another practice has overcome similar challenges we suggest they speak to the GPs there. The data we issue takes account of over-65s but does not weight for deprivation, so the visits have been a good way for us to grasp what individual practices are up against.

The exec has also gained insight into practice staffing issues – for example, a staff member setting up systems for commissioning and then leaving.

The meetings end with drawing up four or five action points for the practice to work on before the next visit. All the practices are trying really hard to make changes and because the visits are by fellow GPs they have never been perceived as anything but facilitative.


Our referrals are now down some 3.35% compared with last year, though our actual secondary care expenditure has not decreased. The next step is to speak to the acute trust about matters such as consultant-to-consultant to referrals, but we have found reducing GP referrals has empowered us to have those conversations.

It’s been interesting to see what’s happened to referrals month by month. The graph on the previous page shows a rise before summer holidays, suggesting GPs chose to refer because they weren’t going to be around as much to manage patients themselves.

The figures for December also prompted our PCT colleagues – as the popular Slade tune puts it – to say they wished it could be Christmas every day. I think this is in part because patients have so much going on in December they’re unlikely to take time out to address a long-term condition.

It seems our practices now see commissioning as part of the core work of general practice. Massive challenges lie ahead, but our executive feels we might just be able to make this work.

Dr Neil Kerfoot is a GP in Bristol and chair of South Gloucestershire consortium and Dr Briony Lodge is a GP in Thornbury and urgent care lead for South Gloucestershire consortium

Dr Briony Lodge: the annual visit allows the exec to see what practices are up against Dr Briony Lodge: the annual visit allows the exec to see what practices are up against