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Referral gateways can improve care

Open letter to Professor Helen Smith, Ms Candace Imison and Dr Johnny Marshall

I note with interest your recent criticisms of referral management centres. As clinical director of a provider of peer-led educational referral management for 48 practices in Brighton and Hove, I have some questions for you.

How many practices log the dispatch and safe arrival of their referral with the intended recipient? How many patients have gone to their GP, rightly upset that they have not received an outpatient appointment, only to find the hospital has ‘lost or not received it'? How many practices do not log two-week cancer referrals to the point when the patient is seen?

To criticise clinical governance at all referral management centres is extremely generalised, and you should also take into account the clinical governance in practices and secondary care.

Over the past quarter at BICS, we have processed 16,486 referrals. We run 22 cross-checks on a weekly basis to ensure safe passage of referrals to secondary care or community clinics.

To date in the last quarter (April to June), BICS received four complaints about clinical triage decisions and four about the administration process. Only two are from GPs – others are from practice managers.

Our triagers, who consist predominantly of GPs and some extended-scope physiotherapists and specialist nurses, are constantly performance managed.

We look at clinical decision making and speed of delivery. They are supported by clinical gateway GP leads on a day-to-day basis. We believe our systems are an improvement on governance between primary and secondary care. You may be thinking, but surely this costs a lot?

Candace Imison calculated that referral management costs £23 per referral. But when the King's Fund researched referral management in 2010, it was based on referral data between 2005 to 2009 and financial data from 2008/09. Some of the centres were in their first year. Any service in start-up phase costs more.

When we started our service, the cost was near Imison's estimation. Since then, we have grown in size by 300%, reducing cost per referral and significantly improving the effectiveness of the gateway.

From Dr Jonathan Serjeant, Pulborough, West Sussex
Clinical director, Brighton Integrated Care Service (BICS)

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