Management (CATS and CAS)
Other chapters on this subject:
PCT initiated Referral
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
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
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
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.
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
• 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
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
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
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
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
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
Diagnostics and Outpatients should become a Primary Care Led service at
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.