Variability in GP Referral Rates to Secondary Care

1
Variability in GP Referral Rates to Secondary Care

• Adam Frosh FRCS(Ed), FRCS(ORL-HNS)
• Consultant ENT Surgeon

2
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

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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

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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.

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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

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Is Variability of Referral Rates Important?

• Appropriateness
• No association yet seen connecting referral rates
  to appropriateness
• Outcomes
• Literature is poor

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Analysis by C. ODonnell 2000

• (i) patient characteristics
• (ii) practice characteristics
• (iii) GP characteristics and
• (iv) access to specialist care

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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

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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 12501252

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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 599600.
• 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 404407.

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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.

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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

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Changing Secondary Care Practice and Systems

• Restricting consultant to consultant referrals
• Hospital waiting list management eg restriction
  of referrals at peak times
• Discharging DNAs generating new referrals
• Early discharge from hospital
• 18 week target increasing supply for demand of
  referrals
• GP visit for aftercare from independent
  healthcare centres

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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 3161974-1976
• 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

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Choose and Book

• Increased availability and awareness of services
• Rejected referrals can generate new referrals
• Inaccurate DOS may create re-referrals

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PBR

• Increased accuracy in coding increases apparent
  referral rates
• Perverse incentives for trusts to miscode f/u as
  new patient

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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

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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

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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

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And finally.
Simply increase the unmet need!
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Primary care pathway for Sleep disorders/ Sleep
apnoea

• BMI gt40 ( consider referral to specialist
• bariatric services)
• Epworth Sleepiness Scale (ESS) gt 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

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ENT Treatments for Snoring

• Relieve obstruction/restriction to nasal airflow
• Excise large tonsils
• UVPP

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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

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Regulation of Referrals from Primary Care to ENT

• Recurrent tonsillitis
• Glue ear
• Hearing loss

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Thresholds of benefit

• Those procedures which do work
• Those which dont work
• Those procedures which work proportionately
  better above a certain threshold eg tonsillectomy
  for tonsillitis

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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 dont work

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Parachute Study