PERFORMANCE: Commissioners in south London have told GPs to curb referral rates after figures showed they rose by 16 per cent in a year.

Bexley Clinical Commissioning Group argued that the increase was hitting its “financial balance and sustainability” in its January board papers and has drawn up proposals to drive down referral rates.

In the first six months of 2014-15 the number of GP referrals was 16 per cent higher than in the same period of 2013-14.


Some GPs believe their performance is being scrutinised unfairly

The rise was significantly above what could be explained by variation in clinical need, demographic changes or population growth, CCG assistant director of transformation and redesign Charles O’Hanlon said.

The CCG also analysed data on accident and emergency attendances, individual funding requests, prescribing and non-elective admissions.

However, some GPs believe their performance is being scrutinised unfairly, and that the higher numbers are actually a result of NHS policies and increases in patient demand.

The CCG contracts a management and booking service referral to ensure that half of referrals are clinically triaged, but the rejection rate of referrals is relatively low, so the CCG is investigating why.

It intends to incentivise practices to peer review each referral before sending it to the referral management and booking service. The CCG is considering introducing locality budgets for elective activity, which will reward “more effective management” by practices. Another option is to introduce mandatory care pathways, requiring a specific “work up” and primary care investigation before referral.

The CCG’s primary care development team has designed a “deep dive” review process to aid analyses of activity at practice, specialty, subspeciality and individual GP level. Sample reports have been produced for practices with especially high referral rates.

The CCG said it has offered reviews to some practices and given advice about where changes can be made to pathways and referral processes. Some practices have “shared ideas” to reduce referral rates.

A CCG spokesman said it is “reviewing data and working with practices to identify the most appropriate actions”.

Despite the concerns about finances, the group is on course for a surplus of £126,000 in 2014-15, in line with its original plans, he added.

Talks are ongoing with GPs on the Bexley Local Medical Committee about which options will be employed where.

The committee argued that increased demand from patients is a significant reason for the rise in referral numbers, and that a lack of clinical pathways for some conditions meant that providers sometimes have to go back to a GP to ask for further referrals for supporting tests.

GPs also said that as part of an incentive scheme to cut hospital admissions – the unplanned admission direct enhanced services – they are increasingly dependent on specialists to help diagnose and treat patients outside hospital.

A further reason for the rise, GPs argued, was that National Institute for Health and Care Excellence guidance on many conditions often now points out the need for specific medication reviews, prescribing, or additional care plans, which can easily lead to extra referrals.

A statement from Londonwide LMCs and Bexley LMC said: “The value judgement that in increase in GP referrals is a cause for concern is questionable, hence the LMC is actively in dialogue with the CCG regarding their perception that the data may in any way be reflective of poor or inappropriate referrals by the GPs in Bexley and to explore how they can support GPs in managing these rising demands.”