£57 million spent on referral management centers is a "National Health Scandal" according to the London Metro. The scandal, according to the Metro is that “firms are being brought in to cut costs by reviewing referrals from GP’s and blocking the ones that they deem unnecessary – without sending staff to see the patients”.
The scandal is not that CCGs are investing money trying to rationalise referrals. The evidence is clear. Up to 40% of referrals to outpatients are a waste of the patient’s time 1,2,3,4,5. At the risk of repetition – these avoidable referrals are a waste of the patient’s time. And it’s not just time that’s wasted. Patients have booked childcare, taken time off work, spend money on car parks. Not to mention their unnecessary concern worrying about how serious their condition is. So trying to reduce unnecessary referrals is not a scandalous withholding of services, it’s about making sure patients are given the most appropriate next step in their care plan and saving them time, worry and cost into the bargain.
The real scandal is not that CCGs are spending money trying to improve the referral process for their patients but that they still believe referral management centers are the answer. Many studies show that referral management centers simply do not work 6,7,8. They slow the referral process down and reviewers do not have enough information to make accurate judgments. In many cases even with the right information, the reviewers are just not knowledgeable enough. GPs refer with the best intentions for their patients care. To be told your referral has been rejected and to have to explain this to your patient is at best embarrassing.
The solution is in better communication between GPs and local specialists and a referral process where both can share the referral decision making with a conversation. That is the solution and where investment should be put. Better communication between GPs and specialists mean referrals are more appropriate, dealt with in an expedited fashion and the decision to refer is a shared one. Until we reject sensationalist headlines and start to think more creatively about integration and improved communication we will continue to waste healthcare investment and a time when we can least afford it.
1. Roland, M. O., Porter, R. W., Matthews, J. G., Redden, J. F., Simonds, G. W., & Bewley, B. (1991). Improving care: a study of orthopaedic outpatient referrals. BMJ, 302(6785), 1124-1128.
2. Elwyn, G. J., & Stott, N. C. (1994). Avoidable referrals? Analysis of 170 consecutive referrals to secondary care. BMJ, 309(6954), 576-578.
3. Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: specialty referrals in the United States. Milbank Quarterly, 89(1), 39-68.
4. Chen, A. H., Murphy, E. J., & Yee Jr, H. F. (2013). eReferral—a new model for integrated care. New England Journal of Medicine, 368(26), 2450-2453.
5. Wood, L., Hendrick, P., Boszczyk, B., & Dunstan, E. (2016). A review of the surgical conversion rate and independent management of spinal extended scope practitioners in a secondary care setting. The Annals of The Royal College of Surgeons of England, 98(03), 187-191.
Reviews of referral management Solutions
6. Imison, C., & Naylor, C. (2010). Referral management. Lessons for success. London: Kings Fund.
7. Blank, L., Baxter, S., Woods, H. B., Goyder, E., Lee, A., Payne, N., & Rimmer, M. (2014). Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract, 64(629), e765-e774.
8. Winpenny, E. M., Miani, C., Pitchforth, E., King, S., & Roland, M. (2016). Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary–secondary care interface. Journal of Health Services Research & Policy, 1355819616648982.