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Crude referral blocks won’t save NHS

It is, we're told, the key to saving the NHS. GPs must ensure patients are treated in the community, where care is cheap, rather than in hospitals, where it is expensive.

It is a simple maxim – almost certainly far, far too simple. Yet the need for efficiency savings is so pressing and so alarming that most NHS leaders seem to be rushing to apply the logic without stopping to question whether it is bunk.

Nowhere is healthcare being planned out so crudely by numbers as in the world of referral management, which our investigation this week reveals has spread across more than half the NHS.

Managers now seem to see it as a test of their machismo to ensure new-style systems for screening GP referrals are far more sweeping, draconian and dramatic than anything that has gone before.

Some are talking of ‘total referral management', which sounds something between a Hollywood action film and a FIFA training scheme. It might even sound quite fun, if we hadn't revealed in some areas as many as one GP referral in eight was being blocked, and 8% refused outright.

It might be tempting to see referral management as the dying spasm of an old regime – one last lash-out by PCTs before their world of balanced scorecards and contract reviews is consigned to NHS history. Of course, it is nothing of the sort. As many as a third of GPs have already received instructions from their commissioning pathfinders about how their referrals will be managed in future. These schemes are clinically led, and some make good sense, but more than a third of GPs warn their new rules are not a sensible basis for promoting efficiency.

So, can the NHS really be saved simply by keeping patients out of hospital? As the logical basis for a mammoth efficiency programme, it has a couple of jumbo-sized flaws. The first is the assumption a cut in hospital attendances automatically means lower costs. It may do, but patients denied hospital treatment will still require care elsewhere, often from a GP practice or community-based GPSI. This is not necessarily much cheaper than treatment in hospital – it just appears so on NHS balance sheets because of the artificially high tariff prices set for secondary care.

The second flaw lies in the unquestioning belief that healthcare systems can be restructured to pare back the need for expensive hospital care. Again, in some cases it probably can, and GP consortia will certainly hope so, as they rush to take on the Government's eye-wateringly tough QIPP targets. But a study this week is just the latest to demonstrate that even after huge underlying restructures in care – in this case for COPD – admissions often keep on coming.

Some senior GP leaders are beginning to talk of a far more sophisticated approach to saving money across the NHS, focused not simply on service redesign, but on improving preventive care for heart disease, diabetes, COPD and stroke. In the meantime, GPs must demand that local referral management schemes are drawn up democratically, deliver extra capacity in the community for those denied hospital care, and above all, offer the prospect of genuine, long-term savings, not quick fixes to the balance books.


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