Intended for healthcare professionals

Analysis And Comment Health policy

Referral management centres: promising innovations or Trojan horses?

BMJ 2006; 332 doi: (Published 06 April 2006) Cite this as: BMJ 2006;332:844

Referral management centres: Hackney carriage not Trojan horse

Davies and Elwyn (1) note the growth of referral management centres
to manage demand from primary to secondary care. They make passing
reference to the variation in referral rates between GP practices. In my
own area this is as much as ten fold between practices working in the same
area and caring for the same socioeconomic and demographic group of
patients. This variation is well recognised (2,3,4,5,6) but poorly
understood. Contributing factors certainly include available resources
within a GP practice and the skills and confidence of the GP in dealing
with particular problems. Thus, the same patient presenting with the same
problem may be managed perfectly well by a GP in one practice but, in
another practice, be referred for a consultant opinion in secondary care,
with all its attendant fears and costs.

It is not so long since these referrals were termed “inappropriate”
by consultants who suggested that these patients should be managed in
primary care. My own view has always been that these were not
“inappropriate referrals” but that there were inadequate responses to deal
with them. Recently, in response to the development of GPs with Special
Interest and Practice Based Commissioning, the gauntlet has been picked up
by PCTs with the development of referral management centres. There is
certainly lack of clarity about the growth of referrals management because
in the same issue as Davies and Elwyn’s paper, Malik, (7) writes in BMJ
careers expounding the virtues of becoming a GP with Special Interest.

It is important that these developments remain clinically led and
focussed. City and Hackney has established a referral management centre to
screen referrals by skilled clinicians, GPs with special interest,
extended scope physiotherapists and clinical nurse specialists. Our
experience has shown that approximately 50% of referrals can be managed
within primary care by these clinicians. Clinical quality is maintained by
regular contact with consultants and the development of joint clinics and
patient satisfaction remains high as measured by patient surveys.

Drife’s commentary (8) on Davies and Elwyn’s paper describes referral
management as a bureaucratic process, bypassing both GPs and consultants.
Our experience is of engagement by GPs and as the range of services
expands, also engagement by consultants. He lauds the entrepreneurial
spirit of general practice and bemoans the “Ukranian tractor factory”
attitude of secondary care, yet treats the primary / secondary interface
as a sacred cow. It is this interface that is challenged by referral
management. It turns the Trojan horse into a Hackney carriage responding
to the individual needs of each patient.


1. Davies M, Elwyn G. Referral management centres: promising
innovations or Trojan horses? BMJ 2006. 332: 844-6

2. Moore AT, Roland MO. How much variation in referral rates among
general practitioners is due to chance. BMJ 1989. 298: 500-2

3. Roland MO, Bartholomew J, Morrell DC, McDermott A, Paul E.
Understanding hospital referral rates: A user’s guide. BMJ 1990. 301: 98-

4. Patterns of referral: Explaining variation. Wilkin D. Hospital
Referrals 1992 ed. Roland MO, Coulter A. Oxford General Practice Series

5. General practitioners attitudes to variations in referral rates
and how these could be managed. Family Practice 1996 13: 259-263

6. Variation in GP referral rates: what can we learn from the
literature? O’Donnell CA. Family Practice 2000. 17; 462-471

7. Malik S. GPs with special interest. BMJ Careers 2006 gp133-4

8. Drife JO. Commentary: Not another innovation. BMJ 2006 332: 847-8

Competing interests:
Clinical Director
Clinical Assessment Service
City and Hackney PCT

Competing interests: No competing interests

11 April 2006
David Keene
GP and Clinical Director, Clinical assessment Service
City and Hackney PCT, London N1 5LZ