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Is a new system needed for GP referral?


Referrals are important to everyone. To GPs, deciding whether or not to make a referral is a core responsibility. To patients, the consequences are profound. And to taxpayers, the costs of GP referrals to the NHS came to £15 billion last year, and have been rising year-on-year for some time. No wonder so much research has been conducted on the area.

Getting under the skin of GP referrals is notoriously tricky. Researchers have invested much energy in assessing the quality of referrals, understanding variations between GP practices, and testing ways of improving referral processes. The evidence base is large and not always consistent, but we can say some things with confidence.

First, decision-making around referral is a complicated process, balancing several competing concerns and sources of information. There are many different reasons why a GP might make a referral, including the patient's need for reassurance or simply to 'do something'.

Second, there is wide variation in referral rates – up to ten-fold between practices. At least some of the variation is accounted for by non-clinical factors such as GPs' willingness to tolerate risk and uncertainty, sensitivity towards patient pressure, or fear of accusations of malpractice.

Third, the quality of some referrals could be improved. Referrals are not always directed to the most appropriate place, and there is evidence of late referral in specialties such as cancer or nephrology. Referral letters sometimes lack the details specialists need.

Fourth, we know that there are systemic barriers making it harder for GPs to make high-quality referrals. Importantly, many GPs feel it is increasingly difficult for them to contact specialists informally to seek advice before deciding whether or not to make a referral.

It is clear that while many GPs make excellent referrals, there is considerable scope for making further improvements. But what should be done? Our research on the quality of GP referral and referral management sheds light on what approaches are most effective.

Firstly – what not to do. In the current financial climate there is a danger of becoming preoccupied with reducing the volume of referrals. An unsophisticated approach to this, for example setting target referral rates, could do more harm than good.

Several areas have established referral management centres which check all GP referral letters before directing them to the most appropriate destination, or rejecting them as unnecessary. These centres may have had some benefits but do not appear to be cost-effective and in some cases undermine referral quality.

Instead, an approach based on peer review and audit of referral patterns among groups of GPs, coupled with a system for harnessing feedback from hospital consultants, holds the greatest promise for improving the quality of referrals while also controlling costs.

The proposals in the government's recent NHS White Paper may help encourage this, by bringing GPs together into commissioning consortia and giving them the incentive to take responsibility for the implications of their referral decisions. As this new system develops, it will be important to ensure that GPs look at the quality of referrals rather than taking a more limited focus on controlling referral volume.