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Referral management: don’t second-guess GPs

31/08/2010
by Rob Findlay

The King’s Fund has just published a new report on referral management, and delivered a cold shower to the referral management centres that some PCTs have created to weed and redirect GP referrals. It concludes:

the greater the degree of intervention, the greater the likelihood that the referral management approach does not present value for money.

Or, as one triaging GP put it:

It gets back to individuals making decisions on other people’s decisions.

Not that everything is rosy in the world of GP referrals. When GPs were allowed to review their colleagues’ referral letters they were not shy about saying what they thought:

When we first started, some of the referrals were absolutely appalling, dreadful. Two lines, referrals of two lines, please see this patient with headaches, and we automatically rejected all of those…

and

I mean, I just couldn’t believe my eyes initially, the quality of referrals was just dire

Well, criticisms are always fun to read. But what did work? In the words of the King’s Fund:

A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective. …

Practice-based commissioning clusters and their successors, the GP commissioning consortia, are the obvious conduit and driver for peer review and audit.

In other words, don’t second-guess the referring GPs; but do work at a doctor-to-doctor level on improving their referral skills. This makes perfect sense. At the time of referral, nobody knows the patient’s condition better than the referring GP. If some GPs aren’t very good at referrals, then the problem is unlikely to be solved by inserting a layer of second-guessers (who have only the inadequate referral letters to base their decisions on). As the King’s Fund says:

any intervention to manage referrals cannot look at the referral in isolation but needs to understand the context in which it is being made

So full marks for the King’s Fund report, then? Very nearly. My slight disagreement is when they say:

any referral management strategy needs to include a robust means of managing the inherent risks at the point when clinical responsibility for a patient is handed over from one clinician to another (so-called clinical hand-offs)

I would argue that they accept the concept of the “clinical hand-off” too readily. Referrals should not be fire-and-forget, rather the GP should remain available as the patient’s advisor after the referral has been made. After all, patients must give their informed consent to every step of their treatment, and both the consultant and the GP have a role to play in informing them.

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