My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

For the NHS the big question is can the number of referrals from GPs to secondary care be reduced?

Filed Under (Clinical Commissioning Groups, GP Commissioning, Health and Social Care Bill, Secretary of State) by Paul on 25-07-2012

…for the Secretary of State it’s, can he claim that his policies have made this happen?

Last week the HSJ revealed an analysis of figures that showed that the recent national downward trend of GP referrals had returned to its historical upward trajectory. In fact the current peak of referrals from GPs is now higher than its previous highest point. This is bad news for the NHS since it shows that current attempts at managing the demand for secondary care do not appear to be working. .

This is probably the key issue for the future of a sustainable NHS. We know that there will be an annual increase in the need for health care over the next decade caused by the increase in the number of older members of society being sicker. Unless this new demand for health care is dealt with through achieving much better value for money than the existing models of care, the NHS will not have the resource to meet the demand.

To thrive the NHS will need to create a model of health care which creates significantly better health outcomes for patients using the same level of resource it does at the moment. This will require changes to the whole system but it also needs to heavily involve change with GPs and their referral behaviour.

Apparently Andrew Lansley had been claiming that the recent fall in GP referrals was the result of his policy of GP-led commissioning. It is of course understandable that he is desperate to find some good news from his reforms.

But this claim, in early 2012, must be a ‘busted flush’. Intellectually he knows that his reformed system is not yet in place. In fact there are no CCGs that are legally authorised to achieve anything. Even though he badly needs some good news to show that his reforms had some rationale (since he gave us no reasons whilst the Bill was being passed) it’s just not possible to claim any national outcomes from a system that is not yet in operation nationally.

I am sure that with the very best CCGs there will have been an impact on overall demand.  But the problem for the Secretary of State is that he has chosen to develop a process that he claims will reform the national programme.  One of his many mistakes was to launch into this national programme before he had found out whether there were sufficient GPs with the interest and the capacity to develop the real commissioning drive to cover every practice in the country.

As many have suggested he could have carried out all of these reforms at a slower and more secure pace. He could have developed and demonstrated models of peer-to-peer relationships clearly reducing GP referrals. These could have taken place in  locations where there was active GP commitment and capability to transform commissioning.

The Secretary of State clearly decided against this.

But in fact even though he thinks he is creating a new national system from 1 April 2013, he won’t. If all goes really well, and with a really favourable following wind, a third of the country will have GPs that are actively involved in transformative commissioning. The others will be playing the same catch up that they would have been if the Secretary of State had instituted this in a phased way.

Whatever laws he may pass reform depends upon the active commitment of real people.

What the Secretary of State is discoveri9ng is that laws are very good at stopping people from doing things. But they are very bad at making people do things when they don’t much want to do them.



7 Responses to “For the NHS the big question is can the number of referrals from GPs to secondary care be reduced?”

  1. I don’t subscribe to HSJ, so haven’t seen the report – but as a GP can comment on GP referals in my practice.
    Looking at the source of referrals received is interesting: across the CCG, only 50-60% come from GPs: the rest come from Consultant to Consultant, A&E, dentists (gone up since anaesthesia in dental surgeries stopped in ?2006??), opticians, self-referral (how did they get in?) and “other”.
    Some of the referrals are the direct result of the way services are organised e.g. to get specialist foot care for diabetics, the patient *has* to be under a diabetic consultant, and I am not clear whether referrals to the Acute Back Pain Clinic (the only entry point for the newly re-established spinal service) count as Consultant referrals or not: all the nurse led clinics have been upgraded to be charged as Consultant Clinics.
    Did the article distinguish between referrals from GPs, and all of those from other sources – some of which may have a motive for making up any shortfall in GP referrals?
    I suppose it isn’t worth pointing out that there is a resource – and patient experience – implication in reducing GP referrals (unless you assume that the referrals were unnecessary in the first place)?
    Either the patient didn’t need referral in the first place OR the treatment was needed but can be performed elsewhere: in the latter case, will resources be provided for the treatment elsewhere?
    Or will the patient be left with their original condition untreated unless the trreatment can be performed by the GP without any additional resources?

    GP capacity, in terms of time, peolpe, space and other rersources is already stretched to breaking point: CCGs, management, QIPP are adding to it – and it looks as though we’ll soon be back to the 2002 work-force situation which led to the new GMS contract: and then where will Mr Lansley’s reforms be?

  2. Mary’s post points out the situation is often more complicated than the headline suggests. Another example: often consultant to consultant referrals are not what you might think e.g. Cardiologist to ECG technician, ortho surgeon to phisio. Efforts to restrict these sometimes have unintended adverse consequences.

  3. Prof Richard Baker et al published a paper March 2012 linking better GP continuity with lower referrals

    We’ve evidence from Dr Simon Coupe that this works – 80% continuity, and 20% lower referrals than peers:, see “new” on left, download the paper. And we have an intervention which can make a step change in continuity. So there is hope, coming from a system change at primary care GP level, not top down.

  4. Looking at the link provided:-
    “We found that GP practices with a higher proportion of patients aged 65 years or greater and of white ethnicity had higher rates of elective hospital admissions. Practices with more male patients and with more patients reporting being able to consult a particular GP had fewer elective hospital admissions.”
    There are so many things mixed up here that it is hard to isolate the factors involved: I would expect more need for referral in patients over 65 to actually need more secondary care interventions: and is it practices with both more male patients *and* reporting easier access to their GP who generate fewer referrals?
    It just doesn’t seem logical to me.

    And Harry: having *all* appointments on a same day basis may (or may not) reduce A&E attendances: what is the evidence that it reduces elective referrals?

  5. Mary, the paper I refer to was written by Richard Baker and his team, and I had no part in it so I am not going to attempt to explain it – they and their reviewers are responsible for the separable effects of the study, hence the finding linking continuity with lower referrals. What I do know is that this is continuity as perceived by the patient, “did you see your usual doctor?” whereas the continuity I am now measuring is statistical, from analysis of consultation records at patient level. If the effect is repeatable, this should give a better correlation if anything – we have not yet been able to repeat it at scale.

    The A&E question is probably a separate one, or at least not closely related. My research showed a link between the method of access giving very rapid access to a GP and 20% lower A&E attendance – there was no measure of continuity involved, and no analysis of the effect on elective referrals. We have not looked for any evidence on this outcome.

    The method I discovered in use and which we now call Patient Access does not prescribe that “all” appointments shall be the same day. But it does enable GPs to offer all patients a choice of when they want to be seen. It is simply an observed and repeatable fact that when offered, around 80% of patients do choose the same day (range is about 70 – 85% in different practices).

    That level of service is plausibly linked to lower A&E use, and merits much larger scale research to broaden the evidence base, especially as it costs less to deliver this service.

  6. By the way, with reference to Paul’s mission statement, this is a fundamental change in the way primary care is delivered within practices. Taken over thousands of practices, it would be a fundamental change to the larger NHS system in which they operate.

  7. A second by the way (forgive me): while none of us want to see costs spirally upwards wastefully, reduction of GP referrals per se cannot be the end goal of the NHS. Referrals are to specialists, presumably because that’s what patients need to make them better, so they are serving a purpose. A lower level, better management in primary and so on would be a good thing, but in terms of sheer waste there may be more to go at in emergency admissions. These are more likely to be the result of system failure rather than clinical decisions.

    I’m at the European Forum for Primary Care conference tomorrow, hoping to find out what is going on elsewhere to see what we can learn.

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