51. Referral Management Systems: Minimizing Cost or Facilitating Harm?

Abstract

Background: Referral Management Systems (RMS) are employed by 90% of primary care organizations. The purpose of RMS is to reduce disparity in referral rates between primary care practitioners, redirect referrals and minimize cost. King's Fund report suggested PCTs with referral management were no more likely to curtail demand than were other PCTs. The importance of early diagnosis and treatment of RA is well established. The Best Practice Tariff for early inflammatory arthritis requires that patients are seen by a rheumatologist within 3 weeks of a GP referral. In our experience, these systems can complicate the patient pathway and introduce harmful delay. A 49 year old woman referred with an ischaemic hand had a stroke whilst a RMS took 3 weeks to process her referral. We saw her the day after receiving the letter, and contend the stroke might have been avoided. This led us to review delay introduced by RMS locally. Methods: Referrals received by one consultant were recorded. Delay from referral date (as per GP entry) to receipt of the referral was documented in days (including weekends). Referrals were received directly from GPs by fax, via Choose and Book (C&B) or via a RMS. Urgency was assessed by the rheumatologist receiving the referral (urgent=to be seen in <3 weeks from GP referral). We contacted the four RMS in our area to process map the RMS pathway and outcomes. Results: In this study 252 referrals were received. 31% of all 252 referrals were adjudged urgent. 11 of 34 (32%) RMS referrals were adjudged urgent by the consultant. Median delay from letter date to receipt was 4 days for direct referrals, 7 days for C&B, and 13 days for RMS. No RMS captured clinical outcomes. One used a rheumatologist to triage, two used GPs and one did not respond. Conclusion: On average, referrals from RMS took the longest to be received when compared with direct referrals. C&B also introduces significant delay. This is not just a local problem. Data from the National Audit Office (2009) indicate that the mean time from referral to first clinic appointment is 6 weeks. The CCG and RMS locally are not measuring clinical outcomes. It is unclear if the service is fit for purpose. RMS claim not to handle urgent referrals, but GPs and RMS seem unable to identify which referrals are urgent. The BMA recommends that the prime purpose [of RMS] is to improve the patient care pathway. It should not lengthen or complicate the patient journey. It must not be simply to save money. Our study has highlighted the necessity for reform in this area. The complexity of referral pathways can cause harm to our patients. This report is going to the CCGs.