Referral management: lessons for success

© The King’s Fund 2010


Referrals to secondary care have been rising

2005-2009

19% growth GP referrals

39% growth consultant referrals

41% growth in ‘other’ referrals


Wide variation referral rate and quality between practices


GP referral – a difficult balancing actIt’s a balance between what I consider to be their needs, and what they consider to be their needs, and their wants and anxieties.

GP, case study site BI think also it has to be cost-effective, so I think you need to have a slightly higher level view of why you’re referring rather than just necessarily pandering to the whims of patients’ requests… At the end of the day this is public money and it has to be spent appropriately.

GP, case study site C

Factors influencing referral decisions• GP factors• Patient factors• Structural factors


Referral management attempts to influence content and pattern of referrals


Yet there is a dearth of evidence about the impact the different approaches to referral management have:

We do not know whether referral management centres will increase or decrease risk, efficiency or choice, and little research evidence exists to support predictions of performance… These centres have appeared overnight in an evidence-free zone.

(Davies and Elwyn 2006, p 845)


We explored the impact on referrals


All approaches have their strengths and weaknesses


There are specific risks from intervening at the point clinical responsibility is passed from one clinician to another…

Some assessors were very keen on rejections and some did very few. Some did so few one had to question their ability to do the job… It gets back to individuals making decisions on other people’s decisions.

(Triage GP, case study B)

Something in the order of 30 per cent of patients, possibly 35 per cent, are not able to be contacted [by the referral management centre] by telephone… It has been much more difficult to get hold of patients than you would expect and I think that’s partly due to the fact that [this area] is just difficult. It’s got a high turnover, lots of addresses are wrong, phone numbers are wrong.

(PCT employee, case study site B)


Desire to improve the quality and manage the pattern of referrals

NHS White Paper puts GPs in charge of commissioning

NHS faces £14-21bn funding gap


Conclusion and recommendations:

• Referral management centres − offer some benefits but are not cost effective and can present risks to quality.

• Peer review and audit with feedback from hospital consultants − most likely to improve quality while controlling costs.

• GP-commissioning consortia may encourage this − but need to take a developmental approach rather than narrow focus on referral volumes.

Health & Medicine

Referral management: lessons for success