Primary care trusts in the South experience more unnecessary referrals than those in the Midlands and the North, data analysis by Dr Foster and HSJ suggests.

The data forms the latest exclusive online Performance Healthcheck for HSJ readers. The analysis is based on the percentage of GP referrals for outpatient appointments that result in no follow-up or admission - suggesting the initial referral may have been unnecessary.

Nine of the 10 PCTs with the highest proportion of referrals with no follow-ups or admissions were in the southern half of the country, the data from 2008-09 shows. Only two of the 10 PCTs with the lowest rates were in the South (see below).

Dr Foster also analysed how much savings each PCT could make by reducing the number of unnecessary referrals.

The data suggests GPs in the NHS Brighton and Hove City area had the highest proportion of referrals which were not followed up, then NHS City and Hackney and NHS Southampton.

The lowest proportion of referrals with no follow-up were in South Birmingham, Barnsley, and Heywood, Middleton and Rochdale.


PCTsTotal first outpatients appointmentsTotal non follow-up of appointments% of non follow-up
Brighton and Hove City PCT39,48411,53829.22%
City and Hackney Teaching PCT36,73010,61728.91%
Southampton City PCT28,7438,24728.69%
Bath and North East Somerset PCT29,2428,16627.93%
Wolverhampton City PCT39,67310,82727.29%
Oxfordshire PCT70,56519,18127.18%
Suffolk PCT89,92524,16326.87%
Cambridgeshire PCT79,69620,93526.27%
Plymouth Teaching PCT41,47610,88826.25%
Eastern and Coastal Kent PCT100,55926,34626.20%


NHS Southampton City clinical director Adrian Higgins said the PCT recognised it previously had a high rate of unnecessary referrals but had made considerable progress in 2009-10 by introducing an “admissions avoidance programme”, which meant that more care was being provided in the community.

Harry Ward, director of commissioning for Wolverhampton City PCT, which had the fifth highest proportion of referrals with no follow ups said: “We recognise that we have outliers and have identified the specialties concerned within our quality, innovation, productivity and prevention programme.”

A spokeswoman for NHS Brighton and Hove City said it had “not been able to replicate the methodology and return the same figures as Dr Foster”. However, she added: “We have moved much of our follow-up activity into the community.”

NHS Eastern and Coastal Kent’s assistant director of commissioning Alison Davis said: “In light of the move to GP consortia and as part of its QIPP programme, the PCT is already aligning staff to support practices in identifying patients who could be better managed through alternative pathways and treatments. We hope this will significantly reduce the number of referrals into secondary care.

“Alongside this, we have asked our GPs to stop referrals into hospitals for low priority procedures.”

A spokeswoman for NHS Cambridgeshire said: “The fact that patients did not need a follow-up appointment does not necessarily mean that they were referred inappropriately. In some cases patients are reviewed by specialists and then managed in primary care. We will be analysing carefully the data produced by Dr Foster.”

A spokeswoman for NHS Plymouth said the PCT was “aware of the level of first appointments without a follow up being offered”.

She said: “Although there may be cases where this is appropriate and offers value to the patient, we have a number of strategies in place to reduce this where these referrals may have been unnecessary.

“The data is based on 2008-09 information and we would expect current data to show a reduction as we have been working closely with Sentinel CIC (referral management service) and our providers in secondary care.”

A spokesman for NHS Suffolk said: “We will study this indicator with interest. Good outpatient practice would be to provide a one-stop service at the first outpatient visit and then return the patient to their GP for follow-up. This indicator seems to discourage this practice.”

A spokesman for NHS City and Hackney said the PCT had been working in partnership with its GPs through practice-based commissioning to effectively manage referrals to acute specialists.

He said: “This has resulted in a reduction of around 4 per cent in first outpatient referrals at a time when other local hospitals are experiencing significant increases in referrals.

“Whilst understanding referral practice is complex, we believe the comparatively high ratio of first to follow-up out patients appointments is primarily a result of proactive management by primary care clinicians rather than inappropriate GP referrals.”