hospital activity - GP referral patterns are not the only important influence on hospital activity. Ann Mitchell explains

Published: 31/01/2002, Volume II2, No. 5790 Page 26 27

How much of a hospital's activity is generated by GP referrals? GP referral patterns have been the subject of research in the past, but most has concentrated on variations between practices and individual GPs.

1It is easy to assume that a large proportion of hospital activity is directly attributable to GP referral behaviour, but the issue may be more complex.This became apparent during a project set up to reduce the number of patients who go from Lanarkshire to Glasgow for their hospital care.

The catalyst came from the building of two new hospitals in Lanarkshire, Hairmyres and Wishaw General, which include some of the most up-todate facilities in Scotland.However, thousands of Lanarkshire residents are still treated in Glasgow hospitals each year.

Analysis showed that a large proportion of the cross-boundary flow is secondary, non-specialist cases, and it was therefore assumed that the scope for reversal was reasonably large.There was an assumption that if we could persuade GPs to refer patients locally, this would substantially reduce cross-boundary flow.

The main focus of the project was to discover why GPs referred in the way they did, and on creating a strategy to address the barriers to local referral.

Cumbernauld and East Kilbride were the areas sending the highest number of patients to Glasgow.This was partly because both are new towns whose populations originally came from Glasgow.

North Glasgow University Hospitals trust provided detailed information on activity generated by Lanarkshire residents which allowed us to identify those practices with a high referral rate.We could also have identified the individual referring GPs.

Information on the episodes of acute inpatient and day case activity available from NGUHT gave a retrospective picture of activity generated by the patients, but did not give the original source of referral or the subsequent reasons for admission.The only way of ascertaining how and why patients got into the system in the first place, and what prompted their admission, was to audit the notes in general practice.With the co-operation of local healthcare councils and GPs, we got access to the notes.

We analysed the total cross-boundary flow (all specialties) in two practices in East Kilbride where cross-boundary flow was relatively small (1,240 episodes in 1999-2000).We also analysed the cross-boundary flow (in one specialty) in two practices in Cumbernauld where the total cross-boundary flow could be measured in the thousands.

In total,186 episodes (15 per cent) were examined (these episodes were generated by 90 patients).The patients came from two similar five-partner practices with a list of around 7,000-7,500 patients.The total cross-boundary flow episodes from East Kilbride during 1999-2000 was 1,240. It had been assumed that around 600 episodes could be reversed from this area.

Each patient identified within the North Glasgow information was traced and, via the patient's notes, the reasons for the admission were identified and categorised.'First referrals'are patients referred, for the first time, to a consultant in Glasgow for a procedure or condition that is routinely managed in Lanarkshire.Procedures not done in Lanarkshire include cardiac surgery, general anaesthetic plastic surgery, specialised laser treatment and lithotripsy.

'Tertiary (Glasgow to Glasgow)' refers to cross-referrals to colleagues for straightforward treatment.Some referrals were made by consultants in Lanarkshire who felt their patients needed specialist tertiary care in Glasgow.

The continuing care group included patients attending for chemotherapy, those in need of regular examinations such as colonoscopy or regular follow-ups.

The cross-boundary flow from Cumbernauld was larger so we looked at urology episodes from two practices.There were 367 episodes for Cumbernauld patients in the year 1999-2000 in North Glasgow.We took a sample of 99 patients who had generated 115 episodes (31 per cent of urology crossboundary flow from Cumbernauld).

Before this examination of patient notes, it had been assumed that around 300 episodes could be reversed within this specialty from Cumbernauld. In the light of what we now know, this target will have to be revised downwards. In both these cases, the reason for patients being treated in Glasgow was not always GP referral.And there were significant numbers of patients who were regular attenders.

As a result of this work, we have a better understanding of how the crossboundary flow is generated and how the activity is measured, and this will inform the debate on referral and activity in a way that would have been impossible if we were just using rates of referral.

2One of the surprising findings was how much activity can be generated within a single admission.

It is clear that changes in practice over the years, such as admitting initially to a surgical or medical receiving unit, contribute to an apparent increase in activity, as does the transfer of patients from ward to ward or consultant to consultant within the same hospital stay.For example, a patient admitted with abdominal pain, which is investigated and then found to be urological in nature, can produce as many as four or five episodes within a stay of two days.

Another issue is the regular practice of referring patients across from one specialty to another within the same hospital, which raises questions about whose choice it should be to make that referral.

To reverse cross-boundary activity, we cannot restrict ourselves to looking simply at GP referrals.More work auditing notes is planned in the next few months, so we will have a more robust model on which to base outplanning assumptions.We have separated the activity into three categories: things we know we can affect - via GPs or others (this group includes the first referrals); things we know we will not affect, such as cardiac surgery; and things we feel are up for discussion about the feasibility of reversal.This third group contains the continuing care patients, the patients with recurrence of symptoms, and the cross-referrals within Glasgow.Working on this group will give opportunities to pursue models of shared care for Lanarkshire residents.

Though the work done in Lanarkshire has only looked at inpatient and daycase activity, it is reasonable to assume that this pattern is repeated in the outpatient workload.The challenge will be to devise ways to overcome the very practical obstacles to reversing cross-boundary flow, such as the transfer of patient information and the agreement on referral protocols and models of shared care.An examination of activity is long overdue, but there has to be an understanding of how it is generated before strategies can be put in place to manage it, measure it and produce qualitative changes for the patients.

Anne Mitchell is project co-ordinator, Lanarkshire cross-boundary flow project, Lanarkshire health board.

Key points

A project to reduce cross-boundary referrals has shown GP referrals have less effect on hospital activity than first thought.

A high proportion of cross-boundary referrals are for procedures not carried out at local hospitals.

The issues involved are complex and scope for reducing these referrals more limited than first believed.

REFERENCES

1Clemence L.To whom do you refer? HSJ 1998;108(5614): 26-7.

2De Marco P, Dain C, Lockwood T, Roland M.How valuable is feedback of information on hospital referral patterns?

BMJ 1993;307(6917): 1465-6.