GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients .
It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons
It’s very difficult to normalise surgeries
Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another.
There are several reasons for the referral
I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition.
We need to look at the bigger picture
The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital.
Education, Education, Education
When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories:
2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker.
2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc.
Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis.
Consultant to Consultant Referral. As advised between consultants.
Patient Choice. Sometimes the patient just wants to see the hospital doctor.
The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below.
Firstly a few disclaimers and thoughts.
– These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures.
– There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right.
– The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption.
– This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further.
In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason.
So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services.
3 Step Plan
As I’m not one to just give problems here are my 3 suggestions to help referrals.
To have a more responsive Layered Outpatient Service.
Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation.
Education, education, education
It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first.
Diagnose Earlier and Refer Appropriately
The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process.
In the end of the day it’s about appropriate referrals always not just a reduction
Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.