GP Referral Management – one view of what the evidence tells us

Evidence around GP referral management



Cochrane review.

Faulkner 2003 – BJGP. overview of types of referral management . BJGP 2003, 53, 878-884

Faulkner   2003 – Cochrane review referral management . Little good evidence – when WASNT this the conclusion of a Cochrane review.

Ringberg, – BJGP 2014; DOI: 10.3399/bjgp14X680521 –

Cox – BJGP June 2013 – -“referral to reassure – maybe when medically less necessary – may reflect acquiescence towards patients”

Cultural reasons that have explanatory power in referral rates may vary.

The higher the referral rates, the more frequently the GPs referred to avoid overlooking anything.

Medical necessity was assessed as a relevant reason in 93% of the referrals, 43.7% by patient preference, 27.5% to avoid overlooking anything, and 14.6% to reassure the patient.

44 GPs / GPs scored the relevance of nine predefined reasons for 595 referrals from 4350 consecutive consultations

aimed to explore associations between reasons for referral to secondary care and patient, GP, and healthcare characteristics.





There is no magic bullet. Sheffield and RCGP – Lee and Blank mainly

Don’t just focus on primary care.

Blank 2013 BJGP

Sheffield Uni -evidence review. I think this then got turned into an RCGP toolkit. Very helpful. some papers coming out of this are

Referral management scheme didn’t change OP attendance. More expensive than internal peer review.

Key points

What is the evidence on interventions to manage referral from primary to specialist non-emergency care.

highlights the complexity of this, and a lack of a neat single answer.




Blank et al NIHR 2014. Health Serv Deliv Res 2015;3(24)

Significant systematic review. Probably last word on the matter.

Slides and 7 pager attached

Read it, understand it, act accordingly.

It’s excellent

There is a comprehensive evidence review on “managing demand in primary care” from Sheffield



Lee- 2013 BJGP is also worth a read.

However, the review identified few studies evaluating these systems, with evidence of their effectiveness in managing demand conflicting

It might take more fundamental revision of existing NHS management and procedures to make these types of changes within the UK.

Possible exceptions to this – the addition or removal of gatekeeping systems and changes to health-care payment systems.

The review, however, highlighted the role of local factors such as waiting times, access to specialists and workload, which may influence the success of any intervention. It is likely that local differences between specialties, UK demographic variation and elements that the review identified relating to individual patients and practitioners will have a stronger impact on the effectiveness and applicability of the interventions identified.

The international evidence suggests that individual peer-review/feedback interventions, and some process change and system change interventions, may be effective and applicable in the UK.

System changes, including the community provision of specialist services by GPs, outreach provision by specialists and the return of inappropriate referrals, appeared to have evidence of effect.

Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient.

The findings suggested that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions.

in order to tackle demand management of primary-care services, the focus cannot be on primary care alone – a whole-systems approach is needed as the introduction of interventions in primary care is often just the starting point of the referral process

multitude of assumptions that are made between interventions and demand management outcomes and that successful referral outcomes are highly dependent on the individuals involved in the referral and also the context in which the referral is taking place.

complexity of the referral process and multiple elements that will impact on intervention outcomes.


what does and does not work?ineffective

A good summary of what we know evidence wise.

 BMJ Open 2015;5:e008592.







Grimshaw and others have produced excellent summaries on Improvement and behaviour change interventions

Educational materials –effectiveness 5%

Some recent systematic reviews do however identify modest effects and, as this intervention is cheap to implement, the changes it brings may be cost effective.


Educational outreach visits- effectiveness 5%-10%


Large scale didactic meetings are generally seen as ineffective, especially if trying to change complex behaviours.


Studies show that the use of opinion leaders to disseminate information has mixed effects on behaviour.


The literature finds mixed effects from audit and feedback, mainly small to moderate positive effects.


Reminders can be moderately effective in changing behaviour, particularly when computer decision-support is used to influence prescribing and the delivery of preventative care services.

Financial incentives small to moderate positive effect

Payment link with clinical outcomes and individual clinicians are more likely to make a difference

Promotion of disease self-management and patients education –effectiveness small to moderate positive effect


Grol et al., 2003. From best evidence to best practice: effective implementation of change in patients’ care.


2. Other stuff

peer review and audit. There is a lot that the quality improvement literature can teach us.

Johnson and May is a decent summary

Table 6 summarises the relative effectiveness of different interventions to change clinician behaviour Educational materials are generally viewed as ineffective in influencing clinician behaviour, despite being the most regularly used intervention.   Outreach visits to professionals in their practice were found to be effective, most notably in changing prescribing behaviour but also in the delivery of preventative services and the management of common problems in general practice.Interactive Educational meetings- effectiveness 11%-20%. Smaller-scale interactive meetings are seen as more effective, although the attributes that make them so are not known.Opinion leaders –effectiveness 10%It is not always clear what the opinion leader does in each study, making general conclusions difficult.Audit and Feedback- effectiveness 5%-10%There is little methodologically sound evidence on the key attributes of this intervention, and how these impact on effectiveness. However, key issues seem to include who provides the feedback, its timeliness, the data’s quality, relevance of content, level of clinician buy-in, and the active or passive nature of the feedback. Reminders –effectiveness 14% The literature suggests mixed effect from financial incentives mainly small positive effect.  There is some evidence that providing educational materials for patients can help the implementation of guidelines. Grimshaw et al., 2004. Effectiveness and efficiency of guideline dissemination and implementation strategies. Jonsson et al 2008. Effective Dissemination of Findings from Research.

Yesterday’s BMJ article – should GP be paid to reduce referrals yes/ no

  • clinicians obtaining second ‘in-house’ opinion prior to referral,
  • involvement of secondary care consultants in educational activities for primary care clinicians, use of structured referral forms,
  • was active dissemination of guidelines,
  • passive dissemination of local referral guidelines,
  • clinicians
  • discussing referral decisions with independent medical advisors,
  • provision of feedback of referral rates,   effective
        • Some practical tips
        • Don’t financially incentivise
        • Personally I’m incredulous.The presentation by Nigel Rowell is very interesting
        • The yes side is in the pdf
        • Attached for completeness


        3. Referral management schemes, services and systems. Be mindful what the evidence says.

        • Many CCGs might consider investment in “GP referral management systems” / “threshold management systems” and similar.
        • The evidence any form of service over and above this make ANY difference is highly debateable at very best, and they add cost. As above – each time it crops up Im assured “it will be different this time”.


        4. Data and numbers – Why should you never aim to deliver a particular referral rate?

        • Her full paper attached for completeness. All CCGs already have a “referral management system”; its called General Practice – very trained clinical brains.Tread carefully here – potential for brute force administrative approaches to fail spectacularly. More effort towards audit, feedback and education. Though this is a slow drip approach. 
        • Candace Imison – Nuffield Trust oct 15.
        • Blanket financial incentives to reduce referrals could harm patients
        • Many factors influence the rates of referral,
        • type of patients a practice serves
        • confidence and skills of the GPs in that practice
        • advanced skills don’t always mean low rates of referral.
        • evidence that under-referral is just as much of a problem as over-referral..Stats lesson‘3 fold variation in bowel cancer mortality shocker……’
          • It’s off topic of ‘referrals’ per se but consider the below
                • Versus what the stats tell is – itmight just be random variation
                • Bowel Cancer Statistics – a funnel plot
                • David Spiegelhalter
                  • Same principle applies to all data on variation. Use data in an informed manner.

                  1. So what can you do to improve the quality of referrals?

                  • manage referrals is to ensure that each practice systematically reviews and audits the referrals it makes.
                  • Comparison with comparable practices – but the rate of referral should be seen as a ‘tin-opener’ to trigger discussion rather than a number on a ‘dial’ of performance.
                  • Close working is also needed between primary and secondary care clinicians to develop clear referral criteria and evidence based guidelines.
                  • clinical decision support tools become embedded in information systems – make the guideline the default – nudge principles of using default and changing the choice architecture.
                  • audit process will unpack training and development needs in GPs and not only improve referrals but enhance a GP’s clinical skills and decision-making.      All up a significant change management task that requires strong clinical leadership from both primary and secondary care, not something to be left the blunt instruments such as financial incentive or crude look at referral rates.

                  6. Summary

                  • Smart use of data – SPC. May take some setting up, but series of run charts
                  • Make sure right evidence is at point of Clincial decision – top tips.
                  • Intervene with outliers – but only with outliers, and do so in a measured way
                  • Peer to peer rather than big stick
                  • Positive deviance – who is managing really well, how, why, what does their data say.
                  • Patient involvement, shared decision making, PDA. Cochrane review on this says it makes a difference. From memory 11% relative difference. Absolutely difference may be small but in a high volume system. Concerns re Clincial time – lengthens consults etc….may be potential for automating some of this – but little evidence that is evidence based.
                  • Control capacity – health care economics 101, supply induced demand.
                  • approach based on peer review and audit of referral patterns among groups of GPs, coupled with a system for harnessing feedback from hospital consultants, holds the greatest promise for improving the quality of referrals while also controlling costs.
                  • In house specialists – not much evidence – double edged, but certainly worth careful thought.
                  • Community capacity / GPwSI – decent evidence. But maybe argued that adds more supply?


                  GF Nov 15



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