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How to peer review practice referrals

By learning from each other, GPs can cut down their referral rates, says Professor Ruth Chambers.

Professor Ruth Chambers: peer review is essentially educational, giving opportunity for reflection and feedback (Photograph: UNP)
Professor Ruth Chambers: peer review is essentially educational, giving opportunity for reflection and feedback (Photograph: UNP)

There's general agreement that GPs should minimise unnecessary referrals to outpatients in order to avoid inconveniencing patients and reduce costs of secondary care.

To do so may mean increased investment in alternative services that increase GPs'

access to investigations or provide community-based care from GPs with special interests or other health professionals.

Any business case for switching outpatient care away from hospital settings and the ensuing consequences has to be clear. The alternative (to retain care by the GP team or refer elsewhere) must be to provide care of at least as high quality and safety as if it had been managed by secondary care, and no more costly.

That said, there seems to be a real potential to reduce numbers of outpatient referrals by GPs and others, which generates fewer follow up outpatient appointments too.

So if GPs are signed up, your first step should be to peer review GP referrals to outpatients. You might conduct the peer review as a practice - looking at each others' referrals; or set up the peer review as a locality or across your primary care organisation.

Peer review as a practice
Decide whether you are going to give feedback on each others' referrals or triage referrals and turn back those that seem to be unnecessary, or too early and require further investigations first, or divert them to an alternative community-based service.

Agree whether you are working as pairs giving mutual feedback, or as an appointed GP or panel which sees all referrals made by practitioners in the practice for peer review or triage.

If you operate as pairs, decide how you include any trainee doctors or locums. If you are single-handed, you could buddy up with a nearby practice.

Agree if this is a short-term learning exercise, for example four weeks, or a permanent system of working.

Peer review is essentially educational, giving opportunities for reflection and feedback. So you'll need to agree that the exercise is all about learning and development rather than performance management or shaming individual GPs about seemingly inappropriate referrals. Feedback should be a constructive two-way process.

If your agreed way is for one or two GPs to peer review every GP's or trainee's referrals then you might decide they can block seemingly inappropriate referrals without the referring GP being present.

The system must not create delays that could potentially harm or inconvenience the patient. If the referral seems urgent but the referral letter is incomplete, you could send it on but ask the GP referring to add more information in parallel.

Reviewer feedback
In the spirit of learning, the GP peer reviewer must feedback their perspectives/judgment in a constructive way to the GP referring.

Agree a template that you can use to judge each referral (see example in box). If you have local GP referral guidelines for each specialty, judgments can be matched against those guidelines or may be various algorithms from Map of Medicine (www.mapofmedicine.com).

If you're running the peer review on a bigger scale you can use a similar approach as for a practice team. GPs learn as much if not more, from being the peer who reviews colleagues' referrals, so encourage all GPs to take a turn on the review panel.

Set up a short-term arrangement for all referrals to be routed to your review centre and diverted from Choose and Book. You'll need all GPs to co-operate with this.

Information from peer reviews should inform potential practice-based commissioning or GP commissioning service redesign/service improvement.

You could run a peer review exercise for a few weeks every few months to see if GPs change their referral behaviour.

  • Professor Chambers is honorary professor at Staffordshire University and a GP in Stoke-on-Trent.

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Try the peer review exercise with one other GP; discuss each of your next 10 referrals before you send them off. Complete the box for each referral to structure the review.
  • Look at your last 10 referrals to hospital outpatients and compare against Map of Medicine. Did you refer appropriately?
  • Compare a referral where your peer thinks you referred too soon or too late against relevant NICE/SIGN guidelines.

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