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.