26 February 2018

RCGP Calls for an End to Referral Management Centres That 'Prioritise Cost-Savings Over Patient Care'

Referral management centres, which are primarily designed to reduce GP total referral numbers to hospital should not be introduced – and where they already exist, it must be demonstrated that they are safe for patients and cost-effective to the whole NHS, recommends the Royal College of GPs in a new report published today.

The report, Quality patient referrals: Right service, right time cites a 'dearth of evidence' that referral management centres – used by around a quarter of Clinical Commissioning Groups in England – are cost-effective, stating that they are ultimately more expensive to run than other systems designed to improve and maintain the quality of GP referrals.

Referral management centres generally perform functions that impose external control measures onto the referrals made by GPs into secondary care, such as triaging referral letters from GPs; linking referrals to booking centres; deciding the treatment route for a patient; diverting referrals to alternative services; and determining whether a referral should not have been made.

The report acknowledges that some referral management centres are judged to be successful by those involved in running and commissioning them, but the College is concerned that some risk patients' safety as clinical decisions are often made in the absence of the patient and without full clinical information.

They also potentially:

  • undermine patient choice and the trust patients have in their GP
  • cost the NHS more in the future, by sending back to the GP for reconsideration of alternative referral routes or when a patient's condition deteriorates
  • undermine GPs' clinical knowledge and professionalism, and relationships between GPs and colleagues in secondary care
  • and further fragment the health system and the patient journey

The RCGP suggests that systems of 'referral support' have been demonstrated to be more effective in improving the quality and appropriateness of GP referrals. Examples of 'referral support' include:

  • Specialist advice services via which GPs can seek advice from consultants by phone or email about management of a patient or whether they think a referral is appropriate
  • Local expertise initiatives whereby GPs with a special interest in a clinical area, or a consultant, work at a community-level to triage referral letters
  • Peer review and reflection whereby another GP or groups of GPs in the practice review referrals before they are submitted to ensure the most appropriate routes and timely use of investigations. This can also be done retrospectively to inform future behaviour.

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: "The purpose of the College is to raise and maintain standards of patient care, so we can't simply sit back and say nothing about some ethically-questionable initiatives that prioritise cost-savings over patient care.

"We understand completely that the NHS is strapped for cash – nowhere is feeling that more acutely than general practice at the moment – and we know that CCGs often have to make difficult decisions. But good quality evidence that referral management centres are cost-effective does not exist.

"What they do is undermine GPs' professionalism and the decisions we make in the best interests of our patients, and in doing so erode the important trust our patients have in us.

"They also overlook that only around one in 20 consultations results in a referral – accounting for just over half of all referrals to secondary care. Family doctors will not make referrals without a good reason for doing so.

"Reviewing referrals is an important part of general practice, and a constructive part of professional development for GPs, but it must be proportionate, safe, and in the best interests of individual patient's health outcomes.

"GPs need referral support, not referral management. We hope that CCGs and other decision-makers in the health service will read this report and take heed of our recommendations, in the best interests of our profession, the wider NHS and our patients."

Robina Shah, Chair of the RCGP's Patient and Carer Partnership Group, said: 'The relationship between a patient and their GP is unique in healthcare and built over time and we must approach any initiatives that threaten this with great caution.

"I trust my GP to make the right decision about my referral - I don't want bureaucracy getting in the way."

Further Information
RCGP Press office: 020 3188 7574/7575/7633/7410
Out of hours: 0203 188 7659

The Royal College of General Practitioners is a network of more than 52,000 family doctors working to improve care for patients. We work to encourage and maintain the highest