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Improving the quality of GP referrals

Dr John Sampson outlines the benefits of taking a new approach to GP referrals to ensure they meet NICE guidelines and empower patients.

Improving GP referrals to hospital services has saved time and money and improved the patient experience
Improving GP referrals to hospital services has saved time and money and improved the patient experience

A groundbreaking approach to the way we refer patients to hospital in our local area has resulted in cost savings of more than £120,000 a year per 100,000 population.

The initiative, drawn up by community interest company South Norfolk Healthcare (SNH), has resulted in a reduction in the number of patients sent to hospital clinics and, at the same time, has improved the quality of referrals to hospital specialists.

This month, SNH’s work, which began in 2010, has won recognition from NICE which has published it as a ‘proven case study’. The initiative was also shortlisted for an enterprise award this summer by GP magazine.

Improving adherence to NICE guidelines

SNH is run by 16 South Norfolk practices working to improve the quality of local healthcare and help prevent patients making wasted trips to hospital. We wanted to support and encourage long-term behaviour change around traditional referral management to improve the quality of GP referrals to secondary care.

Our aims were to make sure referrals were made to the most appropriate place the first time; to ensure patient care was of the highest quality; to avoid clogging the system; and to reduce costs.

Although we were responsible for scrutinising all planned care referrals, we wanted to test a new way of working among a specific group. Since NICE published guidance for lower urinary tract symptoms (LUTS) in May 2010, it made sense that we should test our different approach using referrals for patients with LUTS.

Our main objective was to improve, demonstrably, adherence to NICE guidelines by clinicians in the 16 GP practices in South Norfolk. The focus was on the quality of decision-making between clinician and patient, using peer review of referrals to provide feedback to individual clinicians and empowering our patients so they felt fully informed and supported when dealing with hospital consultants.

Detailed audit

First, SNH performed a detailed audit of all our clinicians’ referrals for LUTS from January 2011 to March 2011.

A total of 320 LUTS and prostate problem referrals and associated hospital outcome letters were jointly audited by employed reviewers - practice clinicians and urology consultants - and assessed using quality markers based on NICE guidance, to check they were appropriate.

Analysis identified doctors’ educational needs and formed the basis for education and training. Clinicians received bi-monthly feedback on referrals against the quality markers to inform and reinforce behaviour change.

Some GPs were, for example, omitting certain information in referral letters such as whether they had fully examined the patient. Feedback given to doctors on how to improve referrals was given in a supportive and uncritical way.

Both clinicians and patients were invited to SNH-arranged educational events and received education packs and patient decision aids. Both were also able to access materials from our website.

Additionally, on the patients’ side, we met their needs by promoting shared decision-making with patient decision aids (which became available in January 2011) for prostate problems.

Raising public awareness

We knew we also had to raise public awareness about this new way of working. We joined forces with various local services: Norfolk County Council launched and advertised patient decision aids within local libraries, advertising them online, on posters and plasma screens, with library staff assisting patients with accessibility; Norfolk and Waveney Prostate Cancer Support Group distributed patient decision aids and raised awareness through its membership; and local parish councils raised awareness via their newsletters.

Our own website was also used to help publicise what we were trying to achieve and update patients on the results.

A year later (from January 2012 to March 2012), we re-audited all LUTS referrals from the 16 practices. The results showed a marked increase in understanding of both shared decision-making and patient decision aids and an increase in the likelihood of clinicians using them.

The audit also showed an increase of 39% for appropriate referrals and demonstrated a significant improvement in the quality of primary care being delivered.

For example:

  • Prostate examination prior to referral improved from 40% to over 70%
  • Investigations for U&Es improved by 43% and urinalysis improved by 36%
  • Use of PSA testing improved by 2%
  • Use of A-blockers increased by 54%
  • Use of combined A-blocker and 5 alpha reductase increased by 54%  

 The re-audit also showed an overall 48% reduction in referrals made by the 16 practices for LUTS of over three months (11 referrals fewer).

Improving quality

Our latest re-audit, carried out from January to March 2013, also showed significant improvements in most quality marker areas. It again demonstrated a quantifiable improvement in the quality of referrals with the percentage of appropriate referrals reaching to more than 80%.

Additionally, the 2013 analysis showed that increased quality of referrals led to shorter wait times for patient appointments.

There had been 206 cases in which peer reviewers felt a patient’s history or symptom-pattern presented a high risk of cancer but that was not indicated in the original referral. As a result, 50 per cent of those referrals were upgraded from routine to high risk, reducing the time to appointment for those patients by two to three months.

There is now scope for further possible savings: by extending the method to more patients than in the 16 member practices at SNH and extending the method over more types of referral.

Supporting clinicians’ focus on quality for their patients has improved care and saved money.

Tips on improving quality of referrals

  •  Look at the evidence and apply it.
  • Don’t take decisions for the clinicians, help and support them to make decisions with patients.
  • Be supportive of clinicians; this is not about being critical of them but offering developmental help through appropriate education.


NICE QIPP case studies: www.evidence.nhs.uk/qipp

  • Dr John Sampson is the former medical director of South Norfolk Healthcare Community Interest Company and a recently retired GP in Norfork.

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