Has there been a change in referral patterns since the start of patient choice?

For an acute trust a change in referral pattern can be a major risk but it may say more about the relationship between the primary care trust and the individual hospital than informed patient choice.

Analysis in this field is in its early stages and a review of the changes that have occurred between acute trusts in London is of interest to see if competition between neighbouring hospitals has become a reality..

Initial changes are anticipated to be in elective activity in the surgical specialties, and the graphs here show some interesting shifts in elective orthopaedics and cardiothoracic surgery. It is clear that there have been some changes in the pattern of activity, but is patient choice the driver?

Referrals in elective orthopaedics and in particular joint surgery are shown in the first graph and demonstrate that referrals from a nearby London PCT to one hospital had increased. The second graph shows that the same acute trust had a reduction in activity from a PCT some distance away with a significant loss of income.

Analysing the data, it would seem that one of the main drivers in the referral pattern was proximity of the hospital to the patient's address. The reduction in waiting times for elective orthopaedic surgery will also mean that fewer patients will be willing to make long and complex journeys for treatment.

For cardiothoracic activity, the third graph shows increases from one PCT that have occurred over an 18-month period with an increased market share of almost 90 per cent at the end of the period compared to 60 per cent at the beginning of the period. The consequence of this change in referral on neighbouring trusts is clearly demonstrated.

Decisions to refer patients to other hospitals can severely affect the income of individual trusts and specialties, and make planning of services increasingly difficult. The variation between quarters demonstrates that provision of operating time and bed allocation needs to mirror the referral pattern but many trusts have not yet achieved this level of sophistication. Knowledge of commissioning intentions will have been agreed during the contract negotiation period but, as the changes in two specialties show, the referrals by PCT and at individual practice level need to be closely monitored by those with planning responsibility at the acute trust.

Paul Robinson is external relationship manager at CHKS.