9. Managing elective activity-referral quality

What is it?

Managing elective (planned) hospital activity by systematically reviewing and auditing referrals with a view to benchmarking against other practices and improving referral quality and by ensuring patients are fully involved in decision-making.

Why is it important?

• GPs make more than 9 million referrals to hospitals for elective care each year that then trigger an annual spend of more than £15 billion in the NHS (McKinsey 2009).
• Referral rates to a particular specialty within a single area vary by as much as 10-fold between GPs (Creed et al 1990; Ashworth et al 2002). There is strong evidence that a wide variety of factors account for this variation, clinical and non-clinical (Foot et al 2010). The available research suggests that not all referrals are necessary in clinical terms, and a substantial proportion of activity is discretionary and avoidable.
• There are also patients who need a referral but fail to receive one. For example, lack of or late referral is thought to be a key driver of poor survival rates for cancer (Department of Health 2011b).
• There is strong evidence to suggest that the quality of referral letters could be improved in some cases (Foot et al 2010). The absence of key information can prevent reliable decisions with regard to risk assessment, triage or resource allocation, as well making it difficult to decide on the most appropriate destination for the referral (Speed and Crisp 2005).
• GPs, patients and specialists do not always share a common understanding of why a referral is being made – for example, whether it is primarily for diagnosis, investigation, treatment or reassurance (Grace and Armstrong 1986, Broomfield et al 2001, Molloy and O'Hare 2003).

What is the impact?

• Given the link between poor outcomes and late referral, particularly for cancer, improving referral quality should have an impact on health outcomes in some cases.
• Improving the quality and appropriateness of referral would have an impact on patient experience by avoiding unnecessary visits and improving the timeliness of treatment.
• There is some scope to reduce costs by avoiding unnecessary referrals. However, this needs to be balanced against the likelihood that improved review and audit processes would also identify under-referral in some clinical areas.
• Referral audit can help to identify training needs and thereby improve the quality and cost-effectiveness of clinical care.

How to do it

The implementation of active referral review should be straightforward for GPs as it requires little investment and can be incorporated within wider audit programmes that should become day-to-day business for practices in the future. Referral review could involve:

• use of comparative information about GP and practice referral rates by specialty and routine audits at practice level
• discussion of a sample of referrals to examine their content and appropriateness
• generalists and specialists agreeing redesigned elective care pathways including consultant-to-consultant referral protocols.

Approaches based on review and audit are recommended over the establishment of referral management centres, which can add a significant overhead cost to each referral, fail to address individual practice deficits, and introduce new clinical risks (Imison and Naylor 2010).

Useful resources

• The King's Fund report on referral management, Referral management: lessons for success (Imison and Naylor 2010), describes the strengths and weaknesses of the different approaches to referral management and provides some practical suggestions of ways to support the referral process.
• There is also a case study on The King's Fund website that provides a detailed description of how one practice has introduced referral management and the impact that it has had.

For further information

• Download all ten priorities: Transforming our health care system
• You can also find all the references mentioned here in that version
• Listen to Candace Imison talk through the ten priorites in our audio slideshow