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   NHS Guidance pdf     Commissioning Web Site     Payment By Results Delay  Primary Care Contracting

Primary Care Based Commissioning
Referral Management (CATS and CAS)

   Other chapters on this subject:

              PCT initiated Referral Management Systems

These are known by a number of names, such as Clinical Advisory Service & Clinical Advisory Treatment Service (CAS & CATS).

Primary Care trusts are trying to find ways to block General Practitioners referring patients to hospital. Under Payment By Results (PBR) hospitals are encouraged to bring in patients and treat them.  PCTs are seeking mechanisms to restrict hospitals' ability to take on all patients.  The PCTs favoured solution is to create another service between G.P.s and hospitals that would vet and delay GP referrals to hospital.

The NHS is addicted to waiting lists. Referral Management systems help NHS finances by recreating waiting lists in primary care, where the waits are not measured.

PCTs congratulated their Hospital Trusts on reducing waiting times and at the same time they chastised them for over-performing, as if the two things were not somehow related.

Now that waiting times have come down and are planned to come down further, the law of diminishing returns starts to kick in.  For details of that and queue theory see the  Nosokinetics web site and Prof Pidd's article  

There are two things you can do with queues: Stop people joining the queue or speed up the service. The latter is very complex and expensive as there are queues within queues (for x-ray, theatre time and so on and other random factors such as patients not arriving smoothly, or joining internal queues from other directions (via casualty) all in a more chaotic manner. When running a system at full capacity the slightest glitch rapidly increases waiting times.

The NHS is once again going to find it almost impossible to keep pushing down waiting lists without even larger increases in activity and costs using the current providers and their costs

So the suggestion is that we should stop people joining the queue by referral management systems (CAS, CATS). Evidence that the centres are effective is lacking, and costs are difficult to predict. Assessment of referrals has the potential to introduce error and delay, and patient flow may be influenced by managers (BMJ article)

Referral Management Centres may reduce costs in the first year, for they will introduce a new queue. Triage systems become the wait for the wait. This time the queue is now in primary care and is not counted anymore. Government Targets only count HOSPITAL waiting times. The delay in treating patients reduces costs in year one. CAS and CATS are a no-brainer double whammy for PCTs. They would seem to reduce costs without impact on any Government measured waiting times!

One of the few interesting things the Modernisation Board produced is the “Big Referral Wizard” document which is now housed on the NATPACT web site. Here are a few quotes:

“Triage is the process by which the service assesses the patient's characteristics and assigns priority to their order in the queue. It is essential to any queuing system that does not employ a FIFO discipline. Triage should be a formal part of the queuing system if FIFO does not operate, even though it adds some delay. However, all too often it is ad hoc. A common issue is that patients may be over prioritised so that there are more and more urgent cases, which inevitably leads to longer and longer waits for the routine cases.”  “It is thus vital that the triage process is regularly evaluated to determine its accuracy. As the length of queues reduces, the usefulness of triage diminishes and a point is reached where triage adds little value. Indeed, triage consumes significant resources which could be used to provide the service rather than order it. Thus one should aim not only for the simplest form of triage but attempt to reduce the length of the queue so that it can be eliminated all together”

That outlines the problems of triage systems, and there is no reason to suspect that we would have any more success with triage systems, or “redirection” systems for referrals.

Referral statistics
The PCTs have produced referral data in various formats which seem to pick out particular practices for special mention because of their “high” referral rates. Small practices are more likely to be singled on charts while no mention is made of the aberrations caused by low list size and low number of doctors. Larger practices will always be nearer “average” because of the averaging effect between different practitioners. Only one referral per month extra would appear to cause a huge jump in referrals per 1000 patients in a small practice. When the Dacorum Alliance of Small Practice’s referral rates are grouped together, referral rates become average for Dacorum.

We are counting private referral rates in Dacorum as they explain some of the variances. In the long term relying on private insurance is risky, as any downturn in the economy reduces private insurance. Furthermore as waiting times come down the main benefit or private insurance falls away… since 70% of private healthcare insurance is now corporate, not individually funded, there could be a cataclysmic decline in private insurance take-up in the next few years.
Chance also plays a role in skewing raw referral statistics. Page 25 of the Big Referral Wizard shows how wide variations is referral rates are returned normal once variance has been taken into account.

A Referral Management System will add to the delay and offer a short term solution by creating waiting lists within Primary Care. It will tackle the small number of referral outliers but that is all. Meanwhile referral management will cause other problems:

• Irritates everyone, including patients, and adds an extra layer of bureaucracy.
• Will increase referral rates overall as you introduce a new service (CAS/CATS) while it delays referrals to hospital
• Could be by-passed by Choose and Book although nowadays PCTs are removing Choice from G.P. systems, whilst offering “Choice” by G.P.s directly is a National Target and command.
• Destructive of Consultant/GP relationships.
• The good prescribing, low prescribing costs and high QOF scores of Dacorum G.P.s would suggest our referral patterns are equally good. Indeed the local referral tool HIDAS web site, which lists hospital counted referrals by practice, confirms that we are below “average” referral rates.
• PBR price design was based on average costs, so they assume there are a very low intensity (i.e. duff) referrals. This  may partly explain current pressure on the trust: Local G.P.  referrals are already of high a quality, and hence costly for the Trust to diagnose and treat. The PCT seeks to add to this by way of reverse of cherry picking; leaving the Provider Trusts with the most expensive patients to treat at tariff price.
• Lack of Evidence for referral management systems: Health Service Journal reports 22nd June 2006 that United Healthcare in the USA abandoned these demand management systems. Dr Richard Smith of United health Europe, said they stopped because they were ineffective. These systems changed very few decisions and irritated patients and doctors. Evidence was lacking on demand management centres and systems focused on reviewing GPs' decisions.

Increasing Referral rates will be created CAS and CATS as you are creating a new "service".
These systems will have the paradoxical effect of increasing referral rates. The “triage” service of NHS Direct has not had the expected effect of reducing A&E attendances. It seems to us that NHS Direct has increased the referral rate to casualty.

Shifting of clinical and insurance RISK over to the PCT.
Every day, with every patient, the G.P. takes the clinical risk and responsibility of not referring a patient to a consultant. Now G.P.s will be able to pass this risk over to the CAS/CAT. So when we have that moment of doubt in the consultation, we can reach for CAS/CATS, de-skilling ourselves further. The de-skilling of General Practitioners, the last bastion of the general physician, is a risk to the profession and to our patients. We are the only people left who can take a holistic view of our patients.

I am aware already of increasing referrals to a CAT: In my own practice I have referred some “rheumatic” patients to the MSK service, where I would have normally been far too embarrassed to send these patients to a consultant clinic. I wonder if, after one year, the exhausted MSK service refers these patients onto a consultant.

CAS/CATS is destructive of clinical relationships with consultants. It extends the "them and us" attitude. At least in fundholding we were able to buy consultant in for teach-and-treat clinics, and engage them clinically from the start

Dacorum G.P.s are good prescribers. Dacorum PCT drugs budget is well below the national average and the prescribing is of good quality. Our QOF scores are all very high. With these high standards what evidence is there to suggest that we are such bad referrers? Of course there are some pretty duff referrals made by all of us, and they stick out like sore thumbs, but the numbers will not be massive.

The PBR tariff was set by assuming that not all referrals would be complex and require investigations and procedures. One of the pressures on West Herts Trust may be because already our referrals are of too high a standard, and that each one requires a lot of work by the Trust costing them much more than the PBR tariff.   The PCT want to se up a reverse of cherry picking, by only sending patients to hospital witch incur the hospitals with greatest costs.

Alternative to CAS and CATS
Why consider referral management? To cut COSTS (good thing). We also hear talk that these services are to offer “improved patient pathways” which is odd as they add another step in the referral process.

What is needed for the health economy is to be able to deliver more at reduced cost. General Practice which is made up of private organisations whose income depends on keeping costs down, are the ideal vehicles to drive such reform. Use what we have now; we do not need to create new organisational structures.

Alternatives to creating Referral Management structures:

1 PCT produce data that takes into account statistical variance which G.P. could work upon

2 Fund G.P.s to audit their referral as if each referral was a critical incident (why, how and better ways, and what learnt). This process could take place within each surgery and can start now, along with improved patient pathway development.

3 Allow G.P.s to be explicit and delay referrals towards year end (as we used to do in the Fundholding era in some specialties).

4 Confirm that G.P.s can setup provider organisations themselves, without the need to tender (providing that they come in at below current tariff prices). G.P.s would need also 3-5 year guarantees that the rules would not change. At the moment G.P.s and PBC has not delivered much as the risk in providing services are too high. A stable regime with fixed rules is needed for G.P.s or others to invest, and to be able to negotiate contracts with consultant providers or NHS Trusts for services.

5 Reduce Hospital costs: Outpatients and Diagnostics as a primary care service, run and managed by primary care.

Rather than setting up new and complex CAS and CATs referral management systems Diagnostics and Outpatients should become a Primary Care Led service at below tariff. 

See how outpatients should be an APMS here

We would prefer to see outpatients with consultants as a primary care resource, using local hospital facilities.

Gerry Bulger                                                                                                 25/11/2006

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