Figures revealing outpatient appointments are set to rise by just 1 per cent this year are being hailed as proof that commissioners have finally curtailed spiralling referrals.
Research, carried out by analysts CHKS for HSJ, shows outpatient attendances rose by 37 per cent during the four years from 2005-06 to 2009-10, with an average yearly increase of 8 per cent. But in 2010-11 the rise is predicted to drop to just 1 per cent.
The slowdown is largely driven by GP referrals, which account for the bulk of outpatient appointments. Attendances following GP referrals are predicted to increase by 2 per cent in 2010-11, compared with 8 per cent the previous year.
However, attendances following referrals between consultants have dipped dramatically and are expected to fall by 5 per cent in 2010-11 after increasing by 23 per cent in 2009-10.
The figures are based on hospital episode statistics. CHKS found there was little seasonal variation in outpatient attendances so was able to extrapolate the first seven months of data for 2010-11 to cover the remaining five months of the financial year.
PCT Network director David Stout said: “It seems to suggest that some of these actions that we have been trying over the past few years have collectively worked. In the past individual PCTs have had an impact [on referrals] but the national picture has been different.
“We would be unlikely to see this level of reduction if it wasn’t happening in most places [across the country].”
PCTs have been targeting referrals as part of attempts to make £20bn of savings by 2014-15.
5%:
Expected fall in attendances following consultant referrals - compared with a 23% rise last year
According to King’s Fund research published last year, 90 per cent have set up referral management schemes to try and divert referrals away from secondary care.
Some commissioners have also introduced peer review to highlight variations in GP referral practice, as well as imposing restrictions on treatments of “low clinical value”.
King’s Fund deputy director of policy Candace Imison said a major driver behind previous increases in referrals had been improvements to waiting times but this was “evening out” as the system adjusted to shorter waits.
Ms Imison warned of the dangers of under-referring and questioned the overall effectiveness of referral management programmes, which were “driving referrals down in secondary care but into triage functions”.
“The evidence is pretty mixed in terms of its value for money,” she said.
Royal College of Surgeons president John Black agreed. “Sometimes a patient needing a joint replacement is being referred to a physio, or even worse referral letters are
sent back or not sent at all,” he said.
East London Integrated Care, a social enterprise which plans to become a commissioning consortium, has reduced GP referrals by 2 per cent. It provides practices with comparative referral and emergency admission rates and has set up an advice service for GPs to contact consultants for advice.
Chief executive Paul Haigh said: “Referral management centres require a lot of outlay in terms of infrastructure to run them. For our model we haven’t had to invest in anything other than our core job.”
British Medical Association GPs committee chair Laurence Buckman said peer review as a commissioning tool was relatively new and the sharp fall was more likely to be a result of the drive to save money.
“The reasons why patients get referred to hospital are complicated; one is because they are ill but it is also patient wish, or if the GP is not sure or needs a second opinion or the hospital has got a technical skill.”
He said a downward trend in GP referrals could only be achieved once more services could be provided in the community.
The predicted steep drop in outpatient attendances after consultant referrals follows an increased focus by PCTs on the practice, which is creating friction with some acute trusts. For example, attempts by NHS South West Essex to impose a protocol on consultant to consultant referrals have been “challenged” by Basildon and Thurrock University Hospitals Foundation Trust.
The trust has raised concerns that some patients referred through non-urgent routes “would [ultimately] have a diagnosis of cancer”, according to board papers.
BMA consultants committee chair Mark Porter said: “It’s hard to argue that PCTs haven’t picked up on some inappropriate referrals, but many consultant to consultant referrals are essential for patient care.” GPs were not always best placed to make diagnoses about specialist areas of medicine, he said.
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