Referral management can save money but its guiding principles must be about quality - not just blanket cuts in numbers referred, say Chris Naylor and Candace Imison
NHS referral management: how to get it right
Referral management in its various guises is becoming standard practice across the NHS. Choose and book data shows that over 90 per cent of primary care trusts already have triage or assessment services that redirect a proportion of referrals away from secondary care (see top chart, opposite page). As budgets tighten, many look on referral management as a way of controlling costs.
Approaches to referral management include anything from dissemination of referral guidelines to full-blown referral management centres which review and triage all GP referrals. New research from The King’s Fund suggests that referral management can help or hinder clinicians in delivering high-quality care. Two things make the difference: how you do it, and why you do it.
The principle focus of much referral management activity to date has been on attempting to reduce unnecessary referrals. Although the evidence does indicate that some referrals are not clinically necessary, focusing on managing demand at the expense of other aspects of referral quality can be counter-productive and potentially dangerous. For example, research suggests that under-referral may be as much of a problem as over-referral.
If financial incentives are introduced to drive blanket reductions in referrals, systems may inadvertently reduce necessary referrals by as much as unnecessary ones.
Our analysis found that areas with the most active referral management regimes had been no more successful than the national average at stemming the rise in referrals to secondary care (see chart).
However, referral management can succeed in improving individual clinicians’ referral skills by introducing new feedback loops, giving GPs increased access to support, and improving their knowledge of local service options.
Evidence suggests there is scope for quality improvement in referral. For example, some referrals are not directed to the most appropriate destination, there is not always adequate information in referral letters, and in some cases insufficient investigations are performed in primary care before making the referral. Improving referral quality in this broader sense should be the primary goal of those designing a referral management strategy. As for how best to do this, the most clinically and cost-effective method appears to be to create mechanisms for systematic peer review and audit of referrals among groups of GPs, supported by consultant feedback, clear referral criteria and evidence-based guidelines. The lack of opportunities to receive feedback on referrals from specialists or to benchmark referral patterns against peers was a serious deficit highlighted by GPs participating in our study.
Practice-based commissioning groups and the new GP commissioning consortia that will succeed them provide the most obvious home for such activities in future.
Value for money
Our research suggests this kind of approach delivers better value for money than more interventionist strategies such as referral management centres. As an additional tier of bureaucracy, referral management centres not only generate substantial additional costs, but can also introduce a new set of clinical risks, particularly those relating to undertaking clinical triage in the absence of the patient. Our research suggests that commissioners are not always aware of such risks when they embark on devising referral management strategies.
A final lesson from our research is that to manage referrals effectively requires a whole-systems approach. It is evident that demand for secondary care cannot be controlled through primary care referral mechanisms alone, since any reductions in GP referrals can be offset by increases in consultant to consultant referrals. Any commissioner interested in controlling the volume of activity in secondary care needs to consider all referral routes and not target just one.
The large variations in referral practice that exist between GPs point to the significant potential for quality improvement.
However, if done crudely, referral management can create more problems than it solves. To be effective, referral management requires careful planning and, crucially, needs to be owned and implemented by GPs and other clinicians.
Seven principles for successful referral management
- 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, 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. A strategy to reduce over-referral could, and indeed should, expose under-referral. This will limit the potential reductions in demand
- Commissioners should not use 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