Do referral management centres threaten choice and competition?

Many referral management centres (RMCs) were originally set up to support patient choice and ensure that primary care trusts hit their 'choose and book' targets.

Now, in an ironic turn of events the Co-operation and Competition Panel (CCP) is questioning whether RMCs are consistent with national policy on free choice of elective care and the principles of co-operation and competition.

The Panel is right to have concerns: most RMCs now serve an entirely different purpose to that intended at the outset. RMCs act as a gateway, sending referrals back or redirecting referrals to out-of-hospital assessment and triage services. A recent Pulse survey suggests that their impact is considerable: four out of five primary care organisations had introduced referral gateways, with some diverting or blocking one in eight referrals.

Advocates argue that RMCs will help GP consortia stick to their budgets by triaging and then diverting – or even refusing – GP referrals into secondary care. However others feel that RMCs inhibit professional freedoms and threaten quality of care.

What everyone does agree on is the wide, unexplained variation in the numbers, rates and quality of GP referrals. There is also good evidence that many referrals are either unnecessary or could be better managed by the GP themselves or other out-of-hospital providers.

The CCP is now considering whether RMCs are justified. But regardless of the impact of RMCs on patient choice, there are more pressing reasons to question whether they are the best approach.

Our previous research on referral management centres suggests that RMCs may not effectively control expenditure. They can exact a high overhead per referral, and if the cost of the alternative service is taken into account, their value for money is questionable. They may also undertake clinical decisions in the absence of full clinical information and thus present clinical risks, especially if based on a poor-quality referral. Plus they can be confusing to patients who may not understand what they are and how they relate to their GP and the hospital.

There are alternatives to RMCs, however. There is growing evidence from GP commissioning groups that peer review and audit can reduce overall referral rates without the clinical risks, while also providing insight into an individual GP's training needs. This type of intervention tackles the problem at its root and potentially at less cost and risk.

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#378 Jonathon Tomlinson

You shouldn't over estimate the clinical criteria, or underestimate diagnostic uncertainty or psychological factors (of both referring clinician and patients)
I've performed an audit of referrals for headaches in my PCT and from the referral letters estimated that approx 40% were unnecessary. Its very hard to say this with certainty because so often there's very little referral information in the letters. In cases I considered referrals unnecessary the letter suggested an insufficient level of GP assessment or trial of treatment. When I met with the referring clinicians non-clinical reasons for referral including feeling pressured by or being unable to reassure patients. Urban GPs in particular are under increasing pressure from their patients who used to the exploitation of commercial based health care in their home countries, where every presentation is an opportunity for a doctor to charge them for a scan. Clinical reasons included lacking confidence in their migraine management skills or being uncertain of the diagnosis. Support and training is more important than rejecting referrals. We contacted the highest referring surgeries and ran sessions on headache management with a local neurologist and myself. We will have to repeat the audit this year to see if referral rates have fallen. The purchaser provider split -the basis of GP Commissioning, forces GPs to try to reduce referrals at the same time as hospitals are competing for more referrals. It has no place in a rational NHS.

#379 W. Beaufort
Hospital doctor

If a GP, Dr A, wishes to refer a patient to a hospital consultant, Dr B, the decision is based on the clinical situation - symptoms, signs, fears - and is an assessment made by a professional. Choose & Book already makes it well nigh impossible for Dr B to alter the appointment if it is not appropriate but he would do so using a wealth of clinical knowledge, but how on earth does a faceless Referral Management Centre (what a dreadful piece of managerial claptrap jargon) presume to interfere with this doctor-patient interaction?
And should something go wrong (missed/late diagnosis, etc) will the RMC take responsibility? Oh no - thought not.
It's programmes like this that make me despair for the future of the NHS. Please get these non-clinical pen-pushing adminstrators out of our service.

#380 Bernard Stacey
Consultant Physician

Ah - well said, Dr Beaufort. Sense at last! Just recently I had a referral on a man with diarrhoea but the letter neglected to mention the past history of a hepatico-jejunostomy. How could even the best clinician (and bear in mind that the best clinicians do not work in Referral Management Centres in any case) make any sort of valued judgement on the appropriateness of the referral?

Do they threaten choice and competition? Yes. But more importantly, they threaten common sense.

#381 Mary E Hoult

Our local NHS trust has an ongong project for CAB during 2011/12,one of the key items is they have introduced the facility for redirecting referrals?which in fact can result in changes to GPs referrals it has just happened to me.My consultant wrote to my GP to suggest I needed a scan, after discussing choice with my GP and making a selection I was shocked to receive an appointment for a service which required me to take 6 buses travel time 3 hours!!!! my GP had given me a copy of his referral and confirmed that it had not been changed by him!!I have raised this with the trust but nobody will own up to who did change my referral each blameing the other.Not a good patient experience.The system is wide open to abuse .

#382 Bernard Stacey
Consultant Physician

Mary, I am sorry to hear of your experience and it will be cold comfort that you are by no means alone. The Choose & Book system is inherently flawed and run and grass-roots level by junior faceless bureaucrats who constantly change and there is never a constant point of contact.
Why this system ever saw the light of day is beyond me and every week we find problems similar to yours. I had hoped that a part of the NHS reforms would be a slimming down of these nuisances but it appears that this government no more understands healthcare than the last one.
Hope your scan goes well though.

#384 Mary E Hoult

What is never taken into account is the fact,once a patient service user joins the paper system by way of C&B or anyother means you are effectively giving up the process over to the unknown!!!!Any NHS employee with a pass word can change your referral or thats how it seem to me.I have had a history of failure of the systems used to provide me timely access which has not been a good patient experience.

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