As Pulse has reported, yet more incentive schemes and gain/share arrangements aimed at reducing referrals are being devised by commissioners. One can strongly argue against the ethics of such schemes.
It has also been reported that the referral rates have gone down nationally. This is certainly a positive story for commissioners, given the immense resource pressures they are having to manage.
The reduction in activity is likely the result of a complex interplay between many factors. But, is it really a welcome story for wider general practice?
Most of us are trying our best to make the fairest use of what we have available
The funding crisis is now so severe and palpable that clinicians on the ground have never been more aware of the funding implications of their decisions, such as on referrals, admissions and prescribing.
It’s true that there is very little point in referring someone with knee osteoarthritis for a knee replacement if they do not want surgery or are grossly unfit for it. So, we may be getting better at asking those questions at the point of referral and discussing the end result of the referral.
And we have acknowledged some potentially avoidable referrals – for example, referral of orthopaedic patients to the pain clinic, before they have really tried the basic steps of the pain ladder that we can deal with in-house. More of us than ever before are administering joint injections in primary care.
There is also more optimal use of skill-mix within the practice teams, with GPs specialising in certain areas such as dermatology. Some surgeries have mechanisms in place to discuss all potential referrals in the wider team before making the final decision. Some areas have also invested in more standardisation of referral via better clinical guidelines, although we do know from published evidence that increased clinical knowledge can also result in increased referral rates.
I suspect most of us are trying our best to make the fairest use of what we have available.
But there is another side to the story too which is not so rosy at all.
Despite national agreements to allow consultant to consultant referrals, there are still some locally agreed restrictions on such referrals, which not only act as a barrier but also, more worryingly, mean some patients may be lost due in the system amongst the ‘did not attends’.
And more and more procedures are now classed under value-based commissioning and require special prior funding approval. The list of such procedures just seems to be getting longer and longer, some of which make little sense.
On the frontline, it feels like we are having to absorb more uncertainty and risk due to referral restrictions and increasingly pressured to deal with vague undifferentiated presentations in-house. We also know that many serious pathologies including some cancers are diagnosed through such referrals. Who is measuring the potential undocumented harm of these restrictions?
These referral restrictions make our day job a lot harder, adding to the difficulty of recruitment and retention in general practice. The worst part of this is that, in line with the inverse care law, the pressures to cut costs and reduce activity are highest in deprived areas, which already struggle to meet the needs of the patients and are struggling most with workforce shortages.
Many practices simply do not have the manpower or the time to be able to put processes in place to optimise referrals. They are probably the worst hit by such incentive schemes, as they lose out when already already struggling.
Unfortunately, the health service also works in a very fragmented fashion and reduction of activity in one part of the system sometimes simply means increased cost for another part of it. A typical scenario would be a declined referral for a knee replacement resulting in more prescribing for pain and increased social care cost. Sadly, quality of life arguments carry very little weight these days, if any.
Moreover, the biggest question of whether reduction in referral activity actually results in cost-savings for hospitals remains unanswered.
It is very obvious though that the referral management systems are simply there to reduce costs and it is time the Government and managers were upfront and honest about it.
Dr Kamal Sidhu is a GP in Blackhall, County Durham