Clinical Governance Practice Leads Workshop
-7th March 2007 – Practice Based Referral Management –

Present – Drs Walker, Gallow, Tiwari, Mapara, Brazier, Allistone, Craske, Brown
Apologies – Drs Lang, Tipple, McMinn

The topic was chosen as the Quality (clinical governance) of referrals is being questioned. Outpatient referrals cost £11.3m compared to £17.2m on prescribing. The latter is analysed in depth but referrals are rarely questioned. 
This is no doubt in some parts due to the autonomous way in which GPs work. However, this concept that the patient-doctor relationship can override the overall health economy in which it takes place is outdated as we move towards a culture of multidisciplinary work, public accountability and re-accreditation.

There was a general discussion on the Practice Feedback to RW’s request on seeing how Practices examine their referrals.

-	Delayed referrals are the commonest cause of complaints and litigation. Is it worth taking the risk of avoiding a referral? Only if the delay was similar to that expected of another GP (Bolam principle). 
-	Fundholding gave savings to benefit the Practice. However, this possibility no longer exists because shopping around for cheaper providers is nullified by Payment by Results…unless GPs or APMSs become providers.
-	Consultants say GPs are good referrers – they would wouldn’t they!
-	How many referrals due to patient anxiety are acceptable?
-	How many referrals due to a GP not knowing enough about a subject is acceptable?
-	Specialised knowledge can be shared among the GPs in a larger practice, but not in a smaller one.

Non GP practice ways of reducing referrals

•	Providing more open access diagnostics for GPs such as breast ultrasound, urodynamics and MRI scans in specific circumstances, may help.
•	CATs are unpopular as they seem to manipulate referrals as opposed to manage them. MSK often directs patients to the wrong specialty- requiring a more appropriate inter referral. Delays in patients receiving appointments abound etc.
•	There needs to be a national debate on whether some services should be paid in part or full by the patient. Foot Health has virtually gone, should early cataract removal for elderly drivers etc. follow?

GP practice ways of reducing referrals

•	It is not unreasonable for Practices to have detailed “clinical” business plans as well as the usual financial/ working resources based plan. This could include
o	Quarterly examination of referrals from PCT data. Determine and plan to remedy areas of significant variation from other local practices.
o	This data could be trailed back to patients so that individual cases could be examined in house. This should be done in a non- threatening and supportive way. The validity of case based discussion is described in ‘Moving on Balint; embracing clinical supervision’ John Launer, JRCGP March 2007p 182-3
o	There could be in-house or individual education to address the potential learning need, which would be included in one’s appraisal.
o	Highlight the referral problems and need for patient cooperation in a Practice’s Patient’s newsletter.
o	Have a practice awareness of GP’s expertise for in house referrals. The GP can concentrate on developing this expertise.

The PCT input into reducing referrals

•	The PCT must support GPs who have to reduce referrals. This includes
o	PALs awareness of the potential patient complaint backlash
o	Support the GP, and not ignore or admonish him, if there is a resulting complaint.
o	Devise a “grey list” for referrals. This is currently in existence but needs to be highlighted and advertised in the same way as prescribing. It needs to be honest, so that reasons for non referrals can be given to the patient. It also needs to be kept up to date.
o	There must be a Public Awareness Campaign in the local press or local radio, so that GPs do not spend their life fighting patients.
o	Reliable referral data needs to be collected and collated for ease of analysis within practices.
•	Ask Consultants and CATs to feedback referral problems

NB.Patient safety is paramount when referring. The above issues relate to situations where harm is extremely unlikely to occur and symptom discomfort is tolerable, with a bit of patient’s responsibility for their own care being thrown in.

Future Meetings

•	I have not arranged a set date for one of these meetings at the moment.
•	There will be an evening meeting in May on the new NICE Osteoporosis guidelines. Increased use of allendronic acid is suggested in line with it coming off tariff.
•	There will be a diabetic task force meeting, possibly in April, with Colin Johnston to see how to take forward diabetic care in Dacorum. This would be an informal lunchtime meeting for Practice Diabetic leads and interested others.
Richard Gallow
Clinical Governance Lead for GPs