Is restricting GP referrals the best way of cutting NHS costs?
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Is restricting GP referrals the best way of cutting NHS costs?
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A report in Pulse says that GPs are facing a new round of efficiency targets and will be making more cuts to referrals until the end of the financial year because PCTs and clinical commissio
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Is restricting GP referrals the best way of cutting NHS costs?
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Is restricting GP referrals the best way of cutting NHS costs?
posted at 6/2/2012 3:01 PM GMT
on bmj.com
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*Moderator*
Posts: 597
First: 17/11/2008 Last: 18/5/2012 |
A report in Pulse says that GPs are facing a new round of efficiency targets and will be making more cuts to referrals until the end of the financial year because PCTs and clinical commissioning groups are falling behind on QIPP targets. Pulse says, "In southwest London Kingston CCG, which has a current shortfall in QIPP savings of £155,000, has announced plans to cut GP referrals by a further 10% between now and April through a new referral management scheme in order to try and meet its targets. PCT minutes said: ‘The remaining gap will be closed through the addition of a referral management scheme. The project plan to be based on a 10% reduction in GP referrals with a financial saving of £975,000 for year end. The addition of the referral management scheme is expected for month five reports with 11/12 impact at quarter four giving estimated savings of £250k.' But is reducing referrals the best way to save money and is it patient centred????? |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 6/2/2012 7:55 PM GMT
on bmj.com
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Posts: 1177
First: 25/1/2009 Last: 18/5/2012 |
So how does the GP decide who not to refer? Should he say no to the enlarging mole, the possible breast lump, the severely arthritic knee in need of replacement? I'll happily admit that many patients come from GPs and dont need anything more than reassurance and sending back again, but how will they make sure they choose the right ones not to send? |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 9:48 AM GMT
on bmj.com
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Posts: 289
First: 13/4/2010 Last: 21/5/2012 |
Over the years I have looked at hundreds of referrals in our practice and can find no significant evidence of inappropriateness or of a lack of good work up and initial appropriate management prior to referral. Yes, in retrospect, there are some referrals which could have been handled differently and referral avoided but these are, literally, few and far between. There has been an unsaid and unwritten assumption amongst some hospital colleagues that GPs refer too much and that higher referral rates are associated with poor quality general practice. However, there is nothing in the literature to back up such assumptions. In general most referrals arise because the GP wants a particular investigation or therapeutic intervention which is not available in primary care or because they have a very specific question that they wish a second opinion (and ideally an answer) on. Referral patterns do vary with age (older patients more likely to be referred) and sex (women more likely to be referred in all but the youngest and oldest age groups) and part of the variation in referral patterns that exist between GPs within an individual practice and between practices may reflect these demographic differences. In addition, deprivation is strongly linked to referral rates, accounting for as much as 29 - 35% of referrals (BMJ 1997; 314: 1456 (17 May)). Particular patient disease groups are more likely to generate referrals (e.g. diabetics). The availability of GPs with a special interest within a practice may affect referrals to that specialty. Logic would suggest that they would reduce referrals to that specialty (e.g. dermatology - BMJ 2002; 325: 1177 (16 Nov)) but other work suggest that GPs with a special interest are more likely to refer to a particular specialty as they are more likely to identify or suspect significant pathology and they are more likely to receive in-house referrals of "difficult cases" from colleagues some of which will need referred on. There have been repeated suggestions about strategies to reduce referrals but the evidence does not seem to support such strategies. A study carried out on referral for back pain by GPs in New Zealand in 2005 (N Z Med J, Vol 118, No 1212 (1 April 2005)) concluded that: The mechanisms which drive variability operate at the level of the specific clinical management option, rather than at the level of the overall approach to management of the disease. Caution should be exercised about claims that reductions in variability will produce reductions in utilisation. A paper from the BMJ in 1993 found that "referral guidelines…unlikely to reduce the number of patients referred to hospital" and may actually result in under-referral (BMJ 1993; 307: 1467 - 70) (4 Dec)) The same paper also looked at "inappropriate" referrals. It found that perceived inappropriate referrals from GPs to secondary care ran at about 15% - exactly the same rate as perceived for referrals between secondary care consultants! Such "inappropriate" referrals may actually reflect a lack of information from secondary to primary care, a lack of resources within primary care, a lack of access to GP beds or a lack of training in particular procedures (BMJ 1994; 309: 576 - 578 (3 Sept)). Finally, we need to put UK referral rates into some kind of context. The UK referral rate is 1 in 7 consultations; in the US the figure is 1 in 3 and the evidence seems to suggest that it is "unlikely that referral guidelines (in the UK) will dramatically enhance specialty capacity by decreasing demand" (BMJ 2002; 325: 370 (17Aug)). Thus there is little in the way of convincing evidence that significant general manipulation of referral rates (presumably in a downward direction) can actually be achieved in practice. It is argued that even if we can reduce referral rates by one referral per GP per week this would have a significant impact on secondary care services. If it could then, of course, it would but I remain to be convinced that such changes will materialize. Moreover, reductions in one area may be countered by recommendations which increase referrals in another area (e.g. early referral of rheumatoid patients for DMARDs; referral of all cerebro-vascular events to the neurovascular clinic; etc).Referal reviews are now a big part of QOF but I am concerned about the chosen method of comparison. The statistics that we have been directed to, which allow us to look at figures for our practice and compare them to other practices in our locality, to other localities, to other CHPs and to the health board area as a whole, are all based on referrals per head of population when all the research tends to refer to referral rates per number of consultations. Clearly doctors who see more patients are more likely to refer more patients. In addition, these statistics don't appear to be weighted for deprivation which is one of the most important determinants of referral rates. So I find it difficult to find these statistics useful or helpful. I remain somewhat unconvinced that it is possible to make significant in-roads into reducing GPs referrals to secondary care. It easy to write guidelines but it is difficult to get them into practice within the confines of each individual consultation. It is unrealistic to expect GPs to refer to guidelines during the consultation each time they see someone that they are considering referring. Few GPs have a comprehensive knowledge of all the relevant guidelines that are out there (such has been the proliferation of guidelines over the last decade) let alone a working knowledge of the contents of each individual guideline as it relates to them in day to day practice and the decision to refer. Many referrals could, perhaps, be avoided if there was another consistent (and friendly!) way to get an opinion from a secondary care colleague. There are still too many secondary care doctors who regard a phone call from a GP as at best an annoyance or irritation. As a GP you only need one unpleasant call with a consultant to ensure that you never phone that consultant for advice again. Why can't we have a generic e.mail address for each specialty where we can send questions or queries to in the knowledge that we will receive a prompt response? This could then be built up into a "frequently asked questions" facility for each specialty. Finally, we should recognise that the vast majority of referrals from the vast majority of GPs are good and appropriate. |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 6:18 PM GMT
on bmj.com
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Posts: 15
First: 20/3/2011 Last: 20/2/2012 |
Would it not cost more in the long run if a gp decided that, to avoid going over their limit, they wouldn't refer a particular patient, but then it turns out that what could have been treated easily at first is now going to be much more difficult? There is always a story in the news about "catching cancer early" so why make it more difficult to do this? What if a gp reaches their limit and then sees a patient that they 100% sure needs to be referred on? Do they just say "sorry, come back next month!" Just out of interest, if this is supposed to be patient centred, how many patients have been asked for their opinion? |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 8:20 PM GMT
on bmj.com
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Posts: 1325
First: 7/3/2009 Last: 21/5/2012 |
No. Simply no. What is this? A GP should be able to refer according to best medical judgement and not according to quotas... This is right ridiculous and unprofessional. If that is the way to save expenses according to some administrators, it will soon become apparent that on the long run it won't save anything, quite the opposite.To tie hands is the lowest possible thing to be done. Those who practice it are no longer devoted to our duty to do our best for our patients. |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 9:04 PM GMT
on bmj.com
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Posts: 261
First: 10/12/2008 Last: 20/3/2012 |
I don't think a cap on referral numbers should ever be considered. I'm a GP in City and Hackney and over the past few years we have done alot of work on trying to reduce the numbers of referrals and improving the quality of referrals. It has paid dividends since we are one of the few PCT's going forward that is not facing a deficit. I think what is key to success here is GP education and closer working with secondary care colleagues. In City and Hackney we are fortunate to have good working realtionships with consultants in our local hospital, the Homerton. We have created care pathways -jointly with GPs and consultants involved. We have looked at specialties such as urology and gynaecology for example - done practice audits on referrals made -did they meet agreed criteria and what subsequently happened in secondary care. Following on from these we have had education sessions with consultants-looking at the results of these audits. GPs have learned a lot and have bought into the quality agenda. We have set up phone advice lines for a number of specialties which are popular with patients -who don't want to go and attend outpatients. Have a look at www.elic.org (and click on information for City and Hackney GPs) Obviously the current climate (and tariff sytem and how hospitals are paid) work against this collaborative approach but we have managed to make it work. Reducing GP referrals will not solve the financial problems of the NHS. Improving the quality of referrals, reducing unnecessary OPD attendance and having good working and mutually supportive relationships with collegues in secondary care saves money and is good for patient care. Kate |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 9:52 PM GMT
on bmj.com
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Posts: 1
First: 7/2/2012 Last: 7/2/2012 |
I think its a touch and go, luckily all GPs I have worked with so far have made referrals only when necessary and have always advised me as such. Its also futile to have such a huge campaign e.g. the recent one on bowel screening then expect referrals to reduce if you're picking up more people as more people come forward as I have seen myself already. Did the projection account for the screening programmes that are/to be implemented and have the bowel screening campaign projected what the referral rate will be? |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 11:13 PM GMT
on bmj.com
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Posts: 5
First: 23/5/2010 Last: 7/2/2012 |
The whole premise of referral reduction is misleading. I am the lead on referral support in my local area and we look as a whole locality at referral quality, because it is the quality of the referral which generates waste. For example, are GPs writing a clear question to their colleagues, is it going to the correct clinic, are investigations being done appropriately or repeatedly. Is the coding of the problem (for payments) accurate. There are many steps along a referral journey and any one of those can result in waste if not done efficiently & in a timely manner. Referal support is a crucial strategy for reducing waste and if applied correctly is a collaborative approach to improving the quality of referrals and not a mallet to crudely restrict the overall number. |
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Re: Is restricting GP referrals the best way of cutting NHS costs?
posted at 7/2/2012 11:26 PM GMT
on bmj.com
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Posts: 428
First: 11/5/2009 Last: 9/2/2012 |
No-one can object to increasing the quality of GP referrals, but restriction of referrals per se pits the GP against the patient. That, for me, is the prime problem with the current NHS reforms in the UK and it can only end in tears... for the GPs. |
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