GP referrals under fire

BMJ 2017; 358 doi: (Published 12 September 2017) Cite this as: BMJ 2017;358:j4228
  1. Zosia Kmietowicz
  1. The BMJ

Is the mandate for GPs to check colleagues’ referrals a good idea? Reactions have been mixed, reports Zosia Kmietowicz

The news that GPs in England are expected to review each other’s referrals to secondary care1 has provoked responses of approval, uneasiness, and hostility among doctors and commissioners.

Practices already running referral peer review stand by their schemes, while some of those that are yet to implement NHS England’s mandate are demanding its withdrawal.

Paul Roblin, chief executive of Berkshire, Buckinghamshire, and Oxfordshire Local Medical Committee, the organisation that represents GPs in the area, said, “Oxford CCG [clinical commissioning group] has tried it before, and it wasn’t found to produce any documentable benefit, so it is planning not to implement the instruction.”

Other CCGs on Roblin’s patch have different ideas about the call to curb referrals. “Bucks CCG is enthused about the instruction, despite the lack of evidence found in Oxford, while Milton Keynes CCG is more equivocal,” Roblin told The BMJ.

Postcode lottery

Roblin believes that allowing local commissioners to decide whether to have referral peer review is wrong and will lead to a postcode lottery. Patients being treated at the same hospital will come from different CCG areas, he points out, some which will have such a scheme and some which won’t.

Roblin also believes that NHS England’s interpretation of the evidence it cites is inaccurate. “Oxfordshire CCG has it right,” he said. “It has tested it [referral peer review] and found that it is time consuming and not beneficial. All CCGs already benchmark referral rates, and those that are outliers are reviewed.”

Peter Holden, from Derby and Derbyshire Local Medical Committee, and a member of BMA Council, denounced referral peer review as a “delaying tactic” and “rationing.” His committee has said no to the policy and backed a request for the BMA’s General Practitioners Committee to reject it at a meeting scheduled for Thursday 14 September.

“They [NHS England] can go whistle,” Holden told The BMJ. “We think this is a no brainer. There is no evidence for this policy. GPC [the General Practitioners Committee] has to stamp its foot and say no. [NHS England] wants us to spend 30 minutes at the end of every day reviewing each other’s referrals. There is plenty of evidence to show that GP referrals are wholly appropriate. We do not randomly refer.”

Luton CCG has been running its scheme of referral peer review since April 2016. The initiative has seen first outpatient referrals to all acute care trusts fall by 8% and those to the local acute care trust by 9.5%, and commissioners could not be happier.

A statement from the CCG said, “Applying evidence based medicine and a team approach to management ensures patients are directed to the most appropriate service from the first appointment. GP practices recognise the benefit in utilising existing clinical expertise within their practice to ensure continued professional development for all clinicians and the benefits this brings for patients.”

Not a priority

GPs in Manchester have been having their referrals to secondary care scrutinised in a peer review scheme for around two years. Tracey Vell, chief executive of Manchester Local Medical Committee, explained that it was largely GPs who did the “checking over” of referrals. “Sometimes it’s for pure content standardisation but also to see if we have missed another service that the patient could be more fruitfully directed to,” she explained.

But Vell was unsure about the wisdom of rolling out the scheme nationally. “I don’t know that I have seen enough in terms of evidence [for a national scheme]. Do I think there are some byproducts that are useful? Anecdotally, yes. It brings up conversations, and any conversations between practitioners tend to improve quality,” Vell told The BMJ. “But we have other things to do before we do that—around the whole process of delivering services closer to home rather than just looking at referrals and deciding whether they are appropriate or not.”

Richard Vautrey, chair of the BMA’s General Practitioners Committee, said that the BMA had raised concerns about the policy with NHS England and that policy makers were considering the feedback. “The reality is that there is no compulsion on practices to engage in this,” he said. “GPs and practices, as CCG members, should ensure that their CCG doesn’t develop a proposal that is going to be counterproductive and provide a further barrier between GPs and specialists, preventing patients from getting access to services that they are entitled to.

“This is in the gift of local CCGs. They don’t have to do this in a prescriptive way. They should work with their local GPs and local medical committees around the issue of appropriate access to services, and they shouldn’t feel compelled to use the approach that is put out in this particular document.”


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