Referral management schemes: good for whom?

Private sector expansion and the widening NHS treatment gap between rich and poor in England: Admissions for NHS-funded elective primary hip and knee replacements between 1997/98 and 2018/19

Parliament has imposed duties on the government and NHS in England aimed at reducing health inequalities. AIM: to understand the effect on inequalities of government policies, which require the NHS in England to outsource elective surgery to the private sector. We analysed the numbers of admissions for hip and knee replacement surgery from the least and most deprived population quintiles in three time periods: before the introduction of the policies (1997/98-2002/03); following the implementation of the independent sector treatment centre programme (2003/04-2006/07); and after the extension of 'choice at referral' (2007/08-2018/19). RESULTS: despite admission rates doubling and trebling for hip and knee replacements, respectively, between 1997/98 and 2018/19, inequality grew to the detriment of the most deprived. Inequality grew at the fastest rate during period 3; admission rates to the NHS fell while admissions to the private sector continued to rise. By 2018/19 almost a third of NHS funded procedures were provided privately. In 1997/98, for every 10 patients admitted for hip and knee surgery from the most deprived quintile, 13 and 9, respectively were admitted from the least deprived, by 2018/19 the gap had widened to 19 and 15, respectively. Socio-economic inequalities for hip and knee replacement have widened as outsourcing of NHS treatment to the private sector has increased. The NHS must rebuild in-house capacity and provision instead of outsourcing care.

Evaluation of the referral management systems (RMS) used by GP practices in Northumberland: a qualitative study

OBJECTIVE

Exploring the views of stakeholders to the referral management systems (RMS) used by GP practices in Northumberland, UK to evaluate its perceived effectiveness.

DESIGN

This was an in-depth qualitative semi-structured interview study.

PARTICIPANTS AND SETTING

32 participants (GPs, hospital consultants, referral support, hospital managers, Clinical Commissioning Group manager) in the North East of England, UK.

METHOD

Interviews using a grounded theory approach and thematic analysis.

RESULTS

The main benefit of RMS mentioned by participants was that it allowed for unnecessary referrals to be vetted by consultants, and helps ensure patients are sent to the correct clinic. Generally, the consultants in our study felt that RMS did not significantly help them reject referrals. Some GPs experienced that RMS undermined GP autonomy and did not help when they had exhausted their abilities to manage a patient in primary care, and it was suggested that in some cases RMS may delay rather than prevent a referral. The main perceived disadvantage of RMS was the additional workload for GPs and consultants, and RMS was felt to be a barrier to commutation between GPs and consultants. Frustration with the system design and lack of knowledge of its cost-effectiveness were articulated.

CONCLUSION

Although RMS was reported to reduce some unnecessary referrals, the effect of referral delay and rejection is unknown. Although there were some positive attributes described, RMS was mostly received negatively by the stakeholders.

Orthodontic referral management systems: Do they make a difference?

Aims:

To assess the performance of the referral management system (RMS) compared to a previous paper-based referral system and to determine whether referrals reflected the patients’ malocclusion and met current guidelines.

Design:

Three-cycle audit.

Setting:

Orthodontic Department, Liverpool University Dental Hospital, UK.

Participants:

Consecutive new orthodontic patient referrals.

Methods:

Data were collected prospectively from orthodontic referral letters and new patient clinic proformas (2016–2017). Cycle 1 assessed the original paper-based referral form, Cycle 2 assessed the first RMS online form and Cycle 3 assessed a modified RMS form.

Results:

Cycles 1, 2 and 3 audited 83, 84 and 81 referrals, respectively. Agreement between the reason for referral and the new patient clinic findings was moderate for Cycles 1 and 3 (Kappa = 0.47 and 0.60, respectively) and fair for Cycle 2 (Kappa = 0.40). In Cycles 1, 2 and 3, the proportion of new patients appropriate for hospital orthodontic care reduced from 52% to 51% and 40%, respectively. None of the three cycles reached the 90% target for compliance with current referral guidelines.

Conclusions:

Cycle 3’s RMS form gave a truer reflection of the patients’ malocclusion but reduced the proportion of appropriate referrals. Further audit is required in this area to investigate the cost-effectiveness and clinical benefits of the RMS.

Impact and cost-effectiveness of formal gastroenterology outpatient referral Clinical Assessment Service

OBJECTIVE

The aim was to assess the financial and operational impact of our new gastroenterology referral pathway model on our services.

DESIGN

An electronic 'Clinical Assessment Service' (CAS) proforma and an information platform were developed, and all data were analysed retrospectively.

SETTING

Royal Wolverhampton NHS Trust.

PATIENTS

14 245 general practitioner (GP) referrals were received during January 2014-December 2016 with 9773 of them being triaged via our CAS.

MAIN OUTCOME MEASURES

We looked into patients' clinical outcome along with departmental performance and finances.

RESULTS

A new outpatient appointment was offered to 60.1% (n=5873) of the CAS referred patients. Endoscopic or radiological investigations were requested for 29.2% (n=2854) of patients prior to deciding on further management plan. Out of those, 27% (n=765) went on to receive another gastroenterology (GI) clinic appointment. The remaining 21.3% (n=2089) of the CAS patients were discharged back to their GP following initial investigations. 5.5% (n=538) were discharged back to primary care with a letter of advice, whereas 5.2% (n=509) were deemed inappropriate for GI clinic and were redirected to other specialists. Overall, 32% (n=3127) of patients were managed without a face to face consultation in the GI clinic. This corresponds to 3136 less outpatient appointments with estimated reduced expenditure by the Clinical Commissioning Group (CCG) of £481K. The 18-week performance and waiting times remained stable despite the increasing referral population. The DNA rate dropped from 14% pre to 8.5%.

CONCLUSIONS

Our clinical assessment model has, in addition to the clinical benefits, a considerable positive financial impact to the health economy.