General practitioners make more than 9 million referrals each year. This page brings together some of the evidence around interventions and approaches around managing demand.

Your suggestions for inclusion are welcome – please contact us.

Search hints: Useful MeSH terms:

• exp REFERRAL AND CONSULTATION/sn [Statistics & Numerical Data]
• exp FAMILY PRACTICE/sn [Statistics & Numerical Data]
• PHYSICIAN’S PRACTICE PATTERNS/
• Combine with the service of interest eg Community Health Services/sn [Statistics & Numerical Data]
• Dont forget to add exp GREAT BRITAIN/

Contents:

• Keep up to date with the latest publications
• Tools and resources
• Sources of  data
• Key reports, policies and research
• Case studies and examples of Referral Management Systems

Keep up to date with the latest publications

• Referral management: rapid evidence scan   October 2016,  by the Strategy Unit, Midland & Lancs CSU,
• Demand management – a collection of documents compiled by the Kings Fund
• Search the Kings Fund library for items on demand management
• Search the Kings Fund website for items on GP referral
• managing demand – a series of case studies from Pulse (Registration required)
• Pulse –  Commissioning Topic – Referrals –including news, articles and case studies. RSS feed available

Tools and Resources

Demand Management: Good Practice Guide (NHS England August 2016) – A list of initiatives and actions that CCGs should consider implementing locally, in collaboration with providers and other organisations, to effectively manage the increasing demand for elective care services (particularly to reduce unnecessary outpatient appointments). Supplemented by case studies.
Summary of actions and initiatives:

• Peer Review of Referrals
• Shared Decision Making
• Choice
• Advice and Guidance
• Alternatives to Outpatient Appointments
• Consultant-to Consultant Referral Protocols
• Direct Access to Diagnostics
• Management and Monitoring of Outpatient
• Follow up Appointments

Resources, guidance and tools for capacity and demand management – Appendix D of Operational resilience and capacity planning for 2014/15 (June 2014)

Demand Management (NHS Institute National Archives page)
A quality and service improvement tool outlining approaches which can be used at various stages of the patient pathway. Includes a number of approaches, tools and websites

The Big Referral Wizard: A Guide to Systems Management in Healthcare (NATPACT)
The wizard is designed to provide you with all the information and tools that you will need to develop an understanding of the various different parts of the referral processes and the systems within which they operate.

Predicting service demand: a simple model
This guidance is based on the practical experiences of one social care shire authority offers a simple and unsophisticated model which comprises 22 separate steps towards predicting social care service demand and responding to this demand.

NICE ‘Referral Advice’ Recommendations Database (NICE)
Primary-to-secondary referral advice from NICE clinical guidelines, cancer service guidance and public health guidance.

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Sources of  data

Monthly Hospital Activity – data relating to elective and non-elective inpatient admissions (FFCEs) and outpatient referrals and attendances for first consultant outpatient appointments. Available by CCG and provider.

NHS Comparators (Registration required) – CLOSED 31 MARCH 2015
The Commissioner View includes useful benchmarking data including Outpatient Follow-up to First Attendance Ratio, total admissions per 1000 broken down by GP practice and specialty.

Hospital Activity data from NHS England – Quarterly activity data relating to GP and other referrals for an outpatient appointment, the total number of attendances at consultant outpatient clinics; including patients seen for their first appointments as well as those attending for subsequent or follow up appointments.  Also, the number of patients who did not attend their outpatient appointment (DNA).

GP Practice data in the NHS IC Indicator portal – data  for hospital activity including A&E attendances, admissions, outpatient appointments and follow up activity by General Practice.

GP “No Follow-up” Rate HSJ Performance Healthcheck
An online tool highlighting the potential savings to be gained by reducing the number of first outpatient attendances that do not have any follow-up appointments or admissions within a given timeframe. Also includes some data on follow up by speciality.

Out-patient referral rates per 1000 patient years at risk, by clinical specialty, age, sex and deprivation category: 1994-98
Analyses of data from the General Practice Research Database: prevalence of disease, GP out-patient referrals to secondary care, prescribing of drugs, management of disease.
IN: Time trends in GP outpatient referrals Health Statistics Quarterly 2001, no 10, pp 14-19

Trends in consultation rates in General Practice 1995-2009 – HSCIC Sept 2009. The last in a series with cumulated data for calendar years 1995 to 2009. It includes analysis by age and sex, the number of consultations for the typical general practice, consultations by  health profession (eg GP or nurse)and on where the consultation took place.

The Centre for Health Economics (CHE) at York University  in their report NHS Productivity from 2004/5 to 2010/11  used data from the annual GP Patient Survey, (the percentage of patients answering “in the past 3 months” to the question “When did you last see a doctor at your GP surgery or health centre?”)  to estimate number of GP consultations and conclude that number of consultations in 2010/11 has fallen back to 2006/7 levels (See Table 7.7).

Key reports, policies and research

• Referral management schemes: good for whom? (BMJ 2017;356:i6856 )
  Schemes to manage demand for hospital appointments are booming, a BMJ investigation has found. But analysis by BMJ indicates that few are being evaluated. Of the 93 schemes identified, 30 are run by private companies, 27 are run in-house by CCGs, 10 are operated by NHS commissioning support units, 10 are run by NHS trusts, nine are run by not-for-profit organisations, and seven are operated by local GPs or other clinicians.
• Referral management centres as a means of reducing outpatients attendances: how do they work and what influences successful implementation and perceived effectiveness? Sarah L. Ball, Joanne Greenhalgh, and Martin Roland. (BMC Fam Pract. 2016; 17: 37 24 Mar 2016 doi:  10.1186/s12875-016-0434-y)
  A qualitative study with a purposive sample of health professionals and managers involved in the commissioning, set-up and running of four referral management centres in England and with GPs referring through these centres.Three themes were identified relating to the context in which RMCs were implemented and managed: the impact of practical and administrative difficulties; the importance and challenge of stakeholder buy-in; and the dependence of perceived effectiveness on the aims and priorities of the scheme.
• Outpatient services and primary care: scoping review, substudies and international comparisons. (Health Services Delivery Research 2016;4(15))
  A review of the published evidence concludes that, with appropriate safeguards and support, substantial areas of care traditionally given in hospitals can be transferred to primary care. Substudies based on interviews were carried out into five areas around the relationship between hospitals and primary care – management centres, in-house review of referrals by GPs,  financial incentives to reduce referrals, consultants contracted to community organisations.
• Demand management for planned care: a realist synthesis.  Health Serv Deliv Res 2016;4(2) The report concludes that there is no ‘preferred intervention’ that has the capacity to outperform all others. There are chapters discussing the evidence around referral management centres, general practitioners with a special interest, direct access to the results of clinical tests and guidelines.  The final chapter offers practitioners some guidance on how they might ‘think through’ all of the interdependencies, which bring demand and capacity into equilibrium.

• What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. (Health Serv Deliv Res 2015;3(24)). This review identified 290 relevant studies, and identified four main types of interventions used to try to improve how referrals are made- educating doctors; making changes to the way referrals are carried out; changing the health-care system; and interventions targeting patients.

• An evidence-based referral management system: insights from a pilot study. (Prim Health Care Res Dev. 2015 Jul;16(4):407-14). A referral management and booking service that combined referral guidelines, online referral templates and administrative and clinical triage was developed by a primary care trust in southeast London involving 13 out of the 46 practices. Overall rates of first outpatient attendances declined more strongly for pilot practices than controls. The number of referrals challenged for being incomplete or having insufficient clinical information decreased. The rate of referrals challenged by clinical triage for not conforming to referral guidelines was well below the rate of inappropriate referrals published in the literature.
• Does GP Practice Size Matter? GP Practice Size and the Quality of Primary Care. An examination by the Institute for Fiscal Studies of trends in the organisation of GP  practices in England between 2004 and 2010, and the relationship between practice size and two indicators of the quality of care: QOF scores; emergency inpatient admissions for ambulatory care sensitive conditions. It also examines the relationship between practice size and outpatient referral behaviour. 

• Derby Advanced Commissioning Referral Audit:An audit of Referral Variation Analysis and Discussion Paper, South Derbyshire CCG August 2014 – An audit of all practices (n=20) in a Derbyshire locality found that up to 25% of GP referrals could be avoided through a combination of better signposting, education, pathway redesign and use of technologies.

• Outpatient Appointment Referrals – results of an online survey of 7,038 adults in England & Wales (April 2014) for NHS England and Monitor. The survey found that 75% had been to their GP in the previous 12 months. Of those who had seen their GP (n= 5,310) 51% had been referred by their GP for an outpatient appointment. See the data tables here.
• Managing customer demand – Understanding and changing behaviours to help meet the financial challenge, LGA July 2013 – an explanation of demand management for local government
• Do referral-management schemes reduce hospital outpatient attendances?  Br J Gen Pract 2013; DOI: 10.3399/bjgp13X668177. A time-series evaluation of primary care referral management over 3 years from 85 practices in one PCT. This evaluation concludes that referral-management schemes did not reduce outpatient attendance rates. RMCs were more expensive than internal peer review.
• GPs put the squeeze on access to hospital care BMJ 2013;347:f4351 – a BMJ investigation (July 2013) into the increasing restrictions imposed by CCG around hospital referrals. See also the BMJ graphic shows which CCGs have not changed, tightened, or expanded their criteria for referral
• Primary Care: Today and Tomorrow – Improving general practice by working differently (Deloitte, March 2012, A discussion of the need for general practice to work differently to cope effectively with the increasing demands it faces.)
• Use of an Electronic Referral System to Improve the Outpatient Primary Care – Specialty Care Interface – report for AHRQ by RAND Corporation, February 2012
• Reducing variation in general practitioner referral rates through clinical engagement and peer review of referrals: a service improvement project. Quality in Primary Care 2011; v 19: p263-72
• Referral Management Schemes Review Effectiveness and cost effectiveness of targeted interventions to reduce unnecessary referrals and improve the quality of referrals from primary care to secondary care (Evidence Adoption Centre, NHS East of England, 2010 – Note the EAC closed Sept 2012 – document loaded here with permission)
• Referral management: lessons for success (Kings Fund, 2010)
• The quality of GP diagnosis and referral (King’s Fund, 2010)
• Approaches to demand management: Commissioning in a cold climate (Kings Fund, 2010)
• Managing capacity and demand across the patient journey (Clinical Medicine, 2010)
• GP referral incentive schemes: GPC guidance for GPs and LMCs (BMA, 2009)
• Factors capable of influencing an increase in GP referral rates to secondary care (England only) (BMA Health Policy and Economic Research Unit, 2009)
• Association between general practice referral rates and patients’ socioeconomic status and access to specialised health care a population-based nationwide study. (Health Policy. 2009 Oct;92(2-3):180-6. Epub 2009 Apr 24.)
• Interventions to improve outpatient referrals from primary care to secondary care (Cochrane systematic review , 2008)
• Referral management principles (BMA Central Consultants and Specialists Committee and GP Committee, 2007)
• Referral Management Pilots In Wales, Follow Up Review. (NHS Wales 2007)
• Can primary care reform reduce demand on hospital outpatient departments? A Research summary (NHS Service Delivery and Organisation Research and Development, 2007)
• Case-mix and variation in specialist referrals in general practice. Br J Gen Pract. 2005 Jul;55(516):529-33.
• Time trends in GP outpatient referrals Health Statistics Quarterly 2001, no 10, pp 14-19.
• Referrals and relationships: in-practice referrals meetings in a general practice. Fam Pract. 2001 Aug;18(4):399-406.
• Why Do Physicians Vary So widely in Their Referral Rates Franks, P. Williams, G.et al. Journal of General Intern Medicine March 2000 Vol 15
• Variation in GP referral rates: what can we learn from the literature? (A systematic review) Family Practice, 17(6) December 2000 , pp. 462-471
• Measuring general practitioner referrals: patient, workload and list size effects. J R Coll Gen Pract. 1988 Nov;38(316):494-7.

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Case studies and examples of Referral Management systems

• Wandsworth RMP
• North Norfolk Healthcare – a CIC based referral management service “to review and administrate acute referrals from all clinicians within member practices”.
• Having it all: efficient and high quality referral management –  Map of Medicine editorial paper (Jan 2014) with articles from guest contributors who share their perspectives on the referral process.
• Introducing new referral gateways – Description of some RMS in a BMJ  article  – ” GPs put the squeeze on access to hospital care” by Gareth Iacobucci (BMJ 2013;347:f4351 (July 2013))
• EDICS – Epsom Downs Integrated Care Systems – consultant-led, local NHS clinics which can both speed up the referral process and allow patients to be seen closer to home in specialist centres rather than hospitals. (Company was placed into Administration on 14 August 2013)
• Implementing a referral management system HSJ 8 October 2012 -the implementation of a referral management system in Abertawe Bro Morgannwg University Health Board (Subscription required)
• Greenwich Referral Management & Booking Service (RMBS) – evaluation report Dec 2012 and presentation June 2013
• Top Tips for implementing a Referral Gateway – one of three reports in Pulse 3 September 2012 describing referral management approaches in three CCGs – Manchester, Cambridge and Corby (Registration required)
• Understanding Referral Practice in Brighton & Hove (Pulse Learning, March  2010. Analysis of the impact of an integrated care gateway on GP referral patterns.)
• Brighton & Hove Integrated Care service – Referral management gateway – BICS is contracted by NHS Brighton and Hove to manage all GP referrals.
• NHS Manchester Referral Management Centre – managed by Harmoni – Brought in house 2012 see here. 
• Kernow Health Referral Management Service – Read the case study in Pulse October 2012
• Implementation of a referral management system in Wales HSJ October 2012
• GPs secure funding for peer review of referrals (Practical Commissioning 15 Nov 2011) – a description of innovation funding obtained by Herts Valleys clinical commissioning group to help them cut their referrals by peer education and support. Lead GPs in each specialty will lead and provide peer-education via virtual surgeries, web resources and educational events as well as ‘up-skilled’ GPs in every large practice. See http://www.hertsvalleysccg.nhs.uk/information-for-health-professionals/better-referral-management/ 

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