Time to step up to the plate in curbing referral over-activity

GP and PCT chief exec Dr Paul Zollinger-Reid looks at what clinicians can do to tackle the rise in referrals to secondary care

So we hear from this very learned journal that GP referrals to secondary care appear to growing, with a national 6% year-on-year rise in the first quarter of 2010/11.

In the East of England overall GP referrals were 104% of what PCTs had planned at the end of June. Equally worryingly, 'other referrals' - these may be consultant-to-consultant referrals or referrals from other health practitioners such as optometrists or physiotherapists - were 120% above plan, with the range being 98% in Luton to 163% in Peterborough (one of my PCTs!).

So what's to be done? Well actually, increasing referrals does not mean increasing activity. In fact, increasing referrals could reflect the use of more services that are specifically in place to manage demand; it is activity that PCTs need to drill down to - outpatient, inpatient day case and procedures.

To sort this each PCT needs a detailed understanding of its activity at each of its providers in all areas of over-activity, both routine and emergency.

Do all PCTs have this? I certainly hope so.

But now to the tricky part. What do we do with it? Well ladies and gents, this is where the white paper comes in.

PCTs have struggled to manage demand. There have been some good attempts at working with docs to manage demand and some really crass attempts that excluded clinicians completely and had predictable effects.

These are clinical issues that can only be solved by clinicians; what is clear is that a significant amount of this activity can't be explained away through 'the burden of disease'.

Part of the explanation will lie in the fact that foundation trusts are getting much slicker at coding and ensuring they record all activity, but largely they're only doing what the rules say. On the whole most foundation trusts are desperate for PCTs to managed demand. We recently audited all our admissions through A&E and were informed that up to 40% of admissions could have been managed in the community. Now OK, we've all heard headline stuff like this before, and no surprises that the majority were falls (patients who were largely sent back home with little change). But even if the number was 10% it is still huge in both numbers and pounds spent.

So we need clinicians to step up to this on two counts. Firstly to use their local knowledge and expertise to put in place clear mechanisms of managing demand, be they protocols for referrals or services to prevent admissions.

And secondly - and this is the rub - we need clinicians to peer review and manage the unacceptable variation we currently have in referral rates. It can't be explained by population characteristics alone.

Which one's my money on? Well we need both; services to support and manage patients in the community are crucial but can we afford, or can consortia afford, to ignore significant variations in referrals?

Dr Paul Zollinger-Read is a GP and chief executive of NHS Cambridgeshire and NHS Peterborough