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Pain, but no gain?

In another note from the dark side, Dr Paul Zollinger-Read looks at PCT methods to reduce GP referrals.

Some of you may have noticed the King's Fund released a report recently on referral management systems. This is a crucial bit of bedtime reading for all developing GP commissioning groups….in fact it's a cracking good read.

The tide of referral growth continues on its relentless upward rise with something like a 4% growth this year compared to last. No one fully understands the reasons behind this growth although there is general agreement that it can't all be pathological and we can't afford it.

PCTs have struggled with this for some time and various solutions have been tried.

We use a supportive approach - I have a first-class public health team that did a similar evidence review to the King's Fund (GP commissioners note - good public health is worth its weight in gold) and they came to the conclusion that we should use a scheme of peer review and encouragment to use referral pathways.

Others have tried naked rationing, but this seems to give short-term gain but also a lot of pain. Although half the PCTs studied believed that their referral management schemes had managed to curtail demand, the evidence did not agree.

The study concluded that a referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective.

Changing referral behavior is far from simple and will require strong clinical leadership from both primary and secondary care, and strong collaboration between primary secondary and community care.

The report points to some other successful strategies such as referral pathways, a focus on reducing procedures of limited clinical value, and comparative benchmarking feedback to GPs.

There's nothing new here but it is very helpful as this is one of the most important challenges we face.

At present our referral rates have fallen by 4% so the approach seems to work. It has yet to translate into a reduction in elective procedures, but the approaches of peer support and collaboration between primary and secondary care seem to be two essential ingredients that we need to build upon.

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

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Dr Paul Zollinger-Read More on GP commissioning at the NAPC Annual Conference

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