Tough choices await CCGs hoping to reverse GP referral trend
Andrew Lansley is not the first health secretary to over-claim the benefits of his policies, neither will he be the last.
His regular claims – and those of other leading healthcare figures who should know better – that the involvement of GPs in commissioning is having a significant impact on changing referral practice, placing less demand on secondary care, have always sounded a little premature. But while referrals were down few people worried about the cause – given the challenges facing the system, good news was to be embraced whatever its source.
But as HSJ’s analysis of the latest referral figures shows, that downward trend has been decisively reversed. GP referrals are now at a level higher than the previous peak. What is more, it appears as if last year’s decline was influenced by the referral management schemes so roundly criticised by Mr Lansley and others. The irony of the health secretary claiming the benefit of actions he was simultaneously attacking will not be lost on primary care trust leaders.
The central question HSJ’s analysis raises is the practicality of clinical commissioning groups working with constituent practices to change referral practice significantly, swiftly and widely enough.
There is no doubt this approach is more desirable than any kind of “top-down” restriction. For one thing, a change in practice is much more sustainable than a central diktat that has to be constantly reinforced and policed.
It is also very early days for CCGs and the “look at the emperor’s new clothes” approach does no favours to these still emergent groups. The most developed CCGs are having some impact on referral practice, but, perfectly understandably, they are the exception. Most CCGs are still focused on authorisation and are likely to remain so for the rest of the year.
Controlling secondary care referrals from GPs is crucial to the financial and structural stability of the NHS. It is worth remembering that “other” referrals made by consultants as well as nursing and allied health professionals are rising steadily. Compared to the concentration on GP referrals there has been very little attention given to this trend. If it continues GP referrals will have to be reduced just for secondary care demand to stand still.
And much more than “standing still” is required. Across the country service redesign and efficiency plans all include ambitious assumptions that GP practices will soak up more demand by providing “care closer to home” and cut the reliance on the acute sector. Crucially this change is expected to be delivered within the next two and a half years. If CCGs are not successful in inspiring what will constitute a revolution in referral practice, then the parts of the system that will come under significant financial strain may outnumber those able to keep their heads above water.
It is perfectly possible this financial impact may affect service quality in an uncontrolled way as parts of the secondary care system break under the strain of rising demand and reducing revenue. It is equally possible that CCGs seeing this possibility may decide that a lesser of two evils would be to adopt some centrally designated treatment restrictions which, like some of those imposed by PCTs, had a good clinical evidence base. Better that, they might reasonably conclude, than dealing with the chaos created by a disintegrating hospital.
Any sensible analysis must determine that it is much too early to tell whether CCGs will be successful in influencing referral practice. The debate worth having is – given the real life context in which CCGs will have to operate – which methods will they forego in meeting that goal and which, however unpalatable, might they need to adopt if the situation warrants it?
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Readers' comments (7)
John Gooderham | 18-Jul-2012 11:42 am
I wonder why there is no mention whatsoever of patients and the public in this piece. I'm not so much bothered by the fact that they are ignored completely, as if they didn't matter, but by the lack of appreciation that informed public involvment could have an vital role to play in reducing demand. Choice of provider is not nearly as important as choosing whether or not to be investigated & treated for conditions that won't get worse. For NHS engagement with patients & the public to be meaningful, there has to be an acceptance that taxpayers sometimes can have a powerful influence on what should not be available.
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Patrick Newman | 18-Jul-2012 11:55 am
A general question of how CCG's will be able to take an objective view of what role GP's should play in referral management has yet to be answered. NHS reforms have probably put back a year or two the solution to this issue that does not envisage blanket solutions or strict protocols that are very resource management orientated. Service redesign is motherhood and apple pie but not a recipe quickly available.
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Sunita Berry | 18-Jul-2012 4:05 pm
Oh dear. Why the continued obsession with GP referrals without actually ever stitching it together with emergency department attendances and the further down the chain, admissions. At present the financial framework is completely misaligned. If tariff could be adjusted such that higher price was payable for OP attendance/emergency attendance that did not result in a secondary intervention or admission, then maybe the CCGs would be forced to consider primary care clinical skills.
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Anonymous | 19-Jul-2012 11:27 am
Lets also not forget the role that AQP will have in increasing both primary and secondary care demand. Checks and balances designed to cap AQP demand will have a direct impact on GP referrals i.e. sending patients back to the GP after a set number of AQP sessions. In addition local partnerships designed to improve appropriate referral at primary care level and minimising onward referral to secondary care, will be significantly weakended when the playing field is opened up to the private sector in the autumn. Years of hard work designed to improve patient care whilst reducing the burden on the wider system will be eroded under AQP. Why are we doing this again?
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harry.longman@patient-access.org.uk | 19-Jul-2012 3:24 pm
We are in grave danger here of losing sight of the purpose of referrals to secondary care. They are clinically based decisions to give patients the skilled attention they need. They are a GOOD THING. They are achieving the purpose of the NHS. They are different in quality from emergency admissions, especially from self-referral, which in many cases can be due to a lack access to professional care. What is sub-optimal is over use of referrals where primary care management would be perfectly good. And there is hope here. Statistical evidence published this year (M Chauhan, R Baker et al) links continuity with lower referrals.
The good news is that if GPs are able to see the right patients, they are better at managing their conditions rather than referring. This turns the problem into one of the system, rather than the professional competence of GPs, or trying to manipulate behaviour by sticks and carrots.
That is where our attention should be focussed.
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Anonymous | 20-Jul-2012 11:12 am
For many the process of getting a referral to secondary care is a deadly one - particularly if you have a poor GP. I hope the private sector do away with this barrier to seeing a "specialist" when symptoms demand further investigation. GPs try this and that and then send for referral if none of the above works - that's why up to 25% of cancers are diagnosed in A&E. I don't see how the latest reconfiguration will change any of this with GPs in charge.
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Anonymous | 20-Jul-2012 11:35 am
Referral Management Systems were only ever a means of counting referrals. The only way they ever reduced the number of referrals is when they lost them down the back of a filing cabinet.
Referral management is about educating GPs and patients in the most appropriate care path for their condition. This not only involves CCGs but hospital consultants as well.
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