PCTs urged to cut referrals by 10%

15 Apr 09

By Nigel Praities

GPs face potentially dramatic curbs on their freedom to send patients to hospital, with many PCTs in England told to cut their outpatient referrals by 10% or more. Rising numbers of GP referrals have already led trusts to scrutinise their hospital activity closely, but those with high levels of referrals will now be named and shamed as the NHS publishes performance league tables for the first time.

The influential NHS Institute for Innovation and Improvement has calculated the number of outpatient referrals each PCT ought to have, based on the age, sex and needs of its local population, and found most need to reduce their rates substantially. The average PCT had a referral rate 9.2% above the calculated ideal level in the quarter two figures for 2008/9, but in some areas rates were 50% higher than expected or more. The worst performer was NHS Berkshire East, with referrals more than 61% above target, although it claimed it had already begun to use practice-based commissioning to curb referral increases.

Norma Southwood, an associate at the NHS Institute for Innovation and Improvement, said the tables would allow PCTs to compare themselves and had identified best practice in high-performing trusts. ‘This is designed to be a prompt for further analysis at trusts. It links in with other work going on at the institute, with the potential to move some activity from the acute sector into the community,’ she said.

Advice accompanying the publication of the tables outlined ‘key steps’ to achieve more efficient outpatient services, including incentivising GPs to reduce referral rates – directly contradicting official GPC advice on referral incentive schemes. ‘PCTs should introduce systems to monitor GP referral rates and provide feedback to them. PBC can be used to incentivise GPs to reduce referral levels where they are overly high,’ it said. PCTs in some areas have taken drastic measures to mitigate the costs of rising numbers of GP referrals, with NHS Devon cancelling its minor injuries enhanced service to save cash. But Dr Adrian Midgley, a GP in Exeter and member of Devon LMC, said the publication of league tables was ill-advised and would worsen the current situation: ‘This is nothing to do with medicine. GPs will see a patient and if the patient can be expected to benefit from seeing a colleague in hospital then we should and will refer them.’

Dr David Jenner, practice-based federation lead at the NHS Alliance and a GP in Cullompton, Devon, said he doubted whether it was possible to accurately predict appropriate referral rates and that the statistics were inappropriate for a PCT performance management tool. ‘Lower referrals may be cheaper, but they may not reflect better practice. This is a tool that rewards cheap practice,’ he said.

Worst performing areas

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61% NHS Berkshire East

55% NHS Mid-Essex

53% NHS Kensington and Chelsea

53% NHS Barnsley

47% NHS Tameside and Glossop

45% NHS Darlington

42% NHS South Tyneside

38% NHS Plymouth

33% NHS Gloucestershire

33% NHS Gateshead

9% National average

-1.5% National top quartile

Proportion of first outpatient referrals above the expected level, given national rates and adjusting for the age, sex and need of a PCT’s population, quarter two 2008/09