Referral management centres: promising innovations or Trojan horses?

doi:10.1136/bmj.332.7545.844

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Myfanwy Davies, research fellow1,
Glyn Elwyn, research professor (elwyng@Cardiff.ac.uk)1

¹ Department of General Practice, Centre for Health Sciences Research, Cardiff University, Heath Park CF14 4YS

Correspondence to: G Elwyn

Accepted 24 January 2006

Referral management centres are intended to improve referrals between primary and secondary care. The aim is good but so far we have little evidence that they can deliver

As demand for health care outstrips supply, interest is increasing in how to manage the referral of patients by one practitioner to another for further care.1 2 Most complex health systems have considered strategies to manage demand. These initiatives began in healthcare services that provide the first point of contact for patients and entail telephone help lines, computer based decision support systems, and practitioner-led triage systems.3 Similar concepts are being developed at the interface between primary and secondary care: one such initiative is a concept known as referral management centres—a centralised process of managing referrals. Despite a lack of evidence about appropriate referrals rates4 5 and the value of such quality improvement initiatives,6 these centres seem to be expected to influence both the volume and quality of requests. Is this realistic?

Why manage referrals?

Many healthcare systems such as those in the United Kingdom, the Netherlands, and some health maintenance organisations in the United States use gatekeepers to regulate the flow of referrals from generalists to more specialised colleagues. Interest in managing demand arose in the US during the mid-1990s as health providers tried to curtail costs.7 Despite these origins, an important facet of managing demand is to encourage referrals to services that are both underused and cost effective.8 The accepted definitions recognise that management is equally concerned with creating and coping with demand as well as curtailing inappropriate flows.

Nevertheless, many initiatives seem to have an emphasis on reducing referrals.9 Referral management centres seem to have been largely set up to monitor the flow of referrals from generalists to specialists and often state that their prime aim …