General practitioners make more than 9 million referrals each year, triggering many billions of pounds of expenditure. There is also significant variation in the quality and rate of referral between GPs and GP practices.
As the NHS faces a prospective funding gap of £14-£20 billion and GPs take the lead for commissioning services, it is the perfect time to examine whether referral management in its many forms will help GP commissioners deliver savings and improve care.
Referral management: lessons for success provides practical advice to those seeking to influence the content and pattern of GP referrals. It draws on the current literature and new qualitative and quantitative research to evaluate the full range of referral management activities from full-scale referral management centres to the 'passive' provision of guidelines to GPs.
A range of interventions and approaches were found to be effective in influencing GP referrals. However, there was evidence that full-scale referral management centres are unlikely to present value for money and some of the new clinical triage and assessment services might add to rather than reduce costs. Instead, a referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective.
The report draws out the following seven lessons that will help GP commissioners ensure that any referral management approach improves quality and make savings.
- Any intervention to manage referrals cannot look at the referral in isolation but needs to understand the context in which the referral is being made.
- Changing referral behaviour is a major change management task that will require strong clinical leadership from both primary and secondary care.
- There are inherent risks at a point of referral, as clinical responsibility is passed from one clinician to another and any referral management strategy needs to have robust means to manage those risks.
- There may be just as much under-referral as over-referral by local GPs. A strategy to reduce over-referral could, and indeed should, expose under-referral. This will limit the potential reductions in demand.
- Commissioners should not introduce financial incentives to drive blanket reductions in referral numbers.
- Reductions in referrals from one source can be negated by rises in referrals from other sources. Any demand management strategy needs to consider all referral routes and not just target one.
- A whole systems strategy will be required to manage demand, with active collaboration between primary, secondary and community care services.