variability in gp referral rates to secondary care adam frosh frcs(ed), frcs(orl-hns) consultant ent...

Variability in GP Referral Rates to Secondary Care

Adam Frosh FRCS(Ed), FRCS(ORL-HNS)

Consultant ENT Surgeon

Background

• 1989 White paper Working for Patients - 20-fold variation in GP referral rates to hospital

• Crombie and Fleming estimated that for a practice population of ~2000 patients, the hospital expenditure (at 1981 prices) associated with the lowest and highest rates of referral were £40,000 and £408,000, a 10-fold difference

Questionable Assumptions

• Increases in referral rates are caused directly and solely by GPs changing their referral behaviour.

• An increase in referrals will represent an increase in inappropriate referrals

• High referral rates reflect inefficiency, poor practice or failure to treat adequately in Primary care

Rise in the number of GP consultations taking place per patient, per year

1995 3.9

2007 5.416

Hippisley-Cox, J. Jumbu, G (2008). Trends in Consultation Rates in General Practice 1995 to 2007: Analysis of the QRESEARCH database. The NHS Information Centre.

Difficulties

• Appropriateness of a referral difficult to define

• Threshold for referrals do not just depend on rigid clinical criteria

• Perhaps – how we can help each other in the referral process most important issue

Is Variability of Referral Rates Important?

• Appropriateness– No association yet seen connecting referral

rates to appropriateness

• Outcomes– Literature is poor

Analysis by C. O’Donnell 2000

• (i) patient characteristics;

• (ii) practice characteristics;

• (iii) GP characteristics; and

• (iv) access to specialist care

Practice Characteristics

• Practice size– 7 papers. Conflicting results

• Geographical location– Some increase in referral activity with

closeness of hospital from the practice

• Fundholding– Only explains 5% variation

GP Characteristics

• No relationship was found between referral rates and age of GP, years of experience or membership of the RCGP in some UK studies

• GPs with a specialist interest in ENT and ophthalmology had high referral rates to these specialities, which persisted after adjusting for case mix – Reynolds GA, Chitnis JG, Roland MO. General practitioner outpatient

referrals: do good doctors refer more patients to hospital? Br Med J 1991; 302: 1250–1252

Access to Specialist Care

• Increasing consultant numbers per area increases referral rates– Roland M, Morris R. Are referrals by general practitioners influenced by

the availability of consultants? Br Med J 1988; 297: 599–600.

• The opening of a district general hospital led to an increase in referral rates for those specialities now providing a local consultant-based service – Noone A, Goldacre M, Coulter A, Seagroatt V. Do referral rates vary

widely between practices and does supply of services affect demand? A study in Milton Keynes and the Oxford region. J R Coll Gen Pract 1989; 39: 404–407.

Influence of Health Initiatives and Policies on Referral Rates

– Practice based commissioning; – Local PCT demand management targets for general

practice; – Care pathway reforms/care closer to home; – Introduction of Clinical Assessment Services (CAS)

and Referral Management Services;

– Increase in availability of non-consultant providers e.g. GPs with special interests (GPwSIs) and nurse-led clinics.

Reasons for Referral to Secondary Care

• Diagnosis• Investigation• Advice on treatment• Specialist treatment• Second opinion• Reassurance for the patient • Sharing the load, or risk, of treating a difficult or

demanding patient• Deterioration in general practitioner-patient relationship,

leading to desire to involve someone else in managing the problem

• Fear of litigation• Direct requests by patients or relatives

Changing Secondary Care Practice and Systems

• Restricting consultant to consultant referrals• Hospital waiting list management eg restriction

of referrals at peak times• Discharging DNA’s generating new referrals• Early discharge from hospital• 18 week target increasing supply for demand of

referrals• GP visit for aftercare from independent

healthcare centres

Changing Primary Care Practice and Systems

• Increasing patient access to primary care increases referral rates to secondary care eg increases need for 2nd opinion

– Coulter, A (1998). Managing demand at the interface between primary and secondary care British Medical Journal 316:1974-1976

• QOF, and GMS contracts increase referrals– Srirangalingam U. Sahathevan S. K. Lasker S. S. Chowdhury T. A. (2006). Changing pattern of referral to a diabetes clinic following implementation of the new UK GP contract. British Journal of General Practice.

56(529):624-6,

• NICE guidance

• Rise of multidisciplinary referrals– Practice nurses– Opticians

• Rise of defensive medicine– Salaried GPs– Locums– Part time working– Erosion of personal lists– Extended opening hours– Walk in centres

• Summerton, N (1995). Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. British Medical Journal 310:27-29

Choose and Book

• Increased availability and awareness of services

• Rejected referrals can generate new referrals

• Inaccurate DOS may create re-referrals

PBR

• Increased accuracy in coding increases apparent referral rates

• Perverse incentives for trusts to miscode f/u as new patient

Changes to the Population

• Ageing population living with diseases– hearing loss– Heart disease– Diabetes– COPD– CVA

• Obesity• New technologies and medical advancement• Information age• Increasing sense of patient entitlement

Conclusions• Highly complex area. • No research into the relationship between national policies and

referral rates • Variations between gp practices’ referral patterns and rates remain

largely unexplained. • Patient, practice and gp characteristics account for less than half of

observed variation• Impact of social class is not clear-cut • No one variable or group of variables appears to be a predictor of

variation• No relationship found between referral rates and age of GP, years

of experience or membership of the RCGP• Conflicting evidence about the relationship between practice size

and variation in referral rates

Conclusions 2

• Vary from PCT to PCT, GP practice to GP practice and even GP to GP

• Unique combination of factors • Timing of impact of any one factor – for example

of choose & book – will not necessarily have immediate effects

• NHS complexity – local health community factors

• PCT-commissioned referral analysis schemes • Analysis by specialty, rather than a focus purely

on average GP referral to hospital figures

And finally….

Simply increase the unmet need!

Primary care pathway for Sleep disorders/ Sleep apnoea

• BMI >40 ( consider referral to specialist• bariatric services)• Epworth Sleepiness Scale (ESS) > 15• Comorbid disease (IHD, TIA, CVA, DM,• respiratory problems, cardiac problems• (heart failure, uncontrolled hypertension,• head injury before onset of symptoms)• Excessive and Intrusive• Sleepiness (EIS) whilst driving• Sleep violence/ unsocial activities• REM related symptoms (cataplexy, sleep• paralysis, sleep onset dreams)• Vigilance critical activity include• commercial driving, pilots.• Any obvious abnormality of nose and• throat• Any strong suspicion of specific sleep• disorder e.g Restless leg syndrome

ENT Treatments for Snoring

• Relieve obstruction/restriction to nasal airflow

• Excise large tonsils

• UVPP

ENT in Primary Care

• GPwSI• ENT CATS• Microsuction• Impedance tympanometry• Pure tone audiometry• Thorough understanding of medical treatments

of rhinitis• Minor operative procedures eg to earlobe• Direct access to physiotherapy services for

dysequilibration

Regulation of Referrals from Primary Care to ENT

• Recurrent tonsillitis

• Glue ear

• Hearing loss

Thresholds of benefit

– Those procedures which do work– Those which don’t work– Those procedures which work proportionately

better above a certain threshold eg tonsillectomy for tonsillitis

Honesty to Patients About Unfunded Procedures

• Admit to patients there are insufficient funds

• Be honest about the evidence for a treatment irrespective of its funding status

• Refrain from dismissing all unfunded treatments as those which don’t work

Parachute Study