Strengths and limitations
To the authors’ knowledge, this is the first study to measure the effects of RMCs on NHS hospital outpatient attendance rates for all specialties. By calculating outcome measures common to all groups and to England, it was possible to measure the effect of referral management locally and determine whether the rate of hospital outpatient attendance was reduced, compared with England. This study involved data from a large population in Norfolk, which collectively attended 376 000 outpatient appointments over 3 years.
Previous studies of referral-management effects have commonly used data on referral rather than outpatient attendance.2–5,12,14 However, referral rates are unsuitable for comparing the effects of referral-management schemes because they are not provided to an NHS minimum data standard, resulting in inconsistent data collection and reporting between data providers over time. Unlike referrals, changes in outpatient attendance have a direct consequence on health-resource consumption.
This study used a retrospective observational design and consequently it was not possible to control for all potentially confounding variables over time. The analysis enabled comparison of changes within and between groups, while accounting for changes in practice list sizes and age distributions over time.
The duration of follow-up, which ranged from 9 to 21 months, should be sufficient to observe the effects of referral management, as changes in GP-referral behaviour would not take more than 18 weeks to affect outpatient attendances under current NHS Referral to Treatment standards. Linear regression results showed that there were no significant trends in mean monthly waiting times for non-admitted appointments, so waiting list changes probably did not affect attendance rates in this study. The authors are not aware of population changes in Norfolk that have increased the need for health services. GP registration rates for people with immigrant status remained lower in Norfolk than in England from 2007/2008 to 2009/2010.
Strategies to reduce over-referral could also potentially reduce under-referral of other patients, and thus limit the potential for reducing overall demand.13 It was not possible to measure referral appropriateness or quality, owing to the lack of agreed standards, although group 2 primarily aimed to reduce inappropriate referrals rather than the number of outpatient attendances. The study did not assess attendance rates for specific specialties, as none of the groups aimed to affect a single specialty. Although referral-management schemes are widespread across England, the authors do not know when individual schemes were introduced.
Referral-management budgets could potentially be misleading. It is not known if all budgets were spent or how budgets were utilised. Also, some of the activities for which RMCs were funded were not directed at reducing outpatient attendances. For example, two RMCs administered booking of secondary care patient appointments on behalf of practices using the national IT Choose and Book system, but they were unable to report what proportion of their budget was allocated to this activity.
A prospective study was not possible in this case, because referral-management schemes were operating before the evaluation started, and would not, in any case, have changed the way in which outpatient attendances were routinely recorded.
Comparison with existing literature
A few studies suggest that a combination of peer review, use of structured guidelines, and specialist feedback can be effective in reducing referral rates when applied to either single or small numbers of specialties.13,14,17 Elsewhere, referral management has reduced referral rates when applied to 10 specialties, using a complex intervention including peer review, reporting, and benchmarking of referral rates and specialist feedback.18 However, the intervention was unsuccessful in one specialty when specialist feedback was excluded. The relative importance of each specific component in effective referral management is not well understood.
Previous research suggests that more active forms of referral management such as RMCs are less likely to offer value for money.13,16 The present study found that the effect of RMCs, which were the most expensive intervention type, was no better than lower-cost internal peer review. Of the five approaches studied, the least effective was a higher-cost RMC.
Implications for research and practice
The lack of effect found by this study suggests that a cautious approach should be taken to adopting referral management, particularly if undertaking a wide range of activities across multiple specialties. Given the widespread use of referral management, evaluation is needed to understand the relative importance of each component in referral-management interventions, if referral management is to be applied effectively to reduce outpatient attendances.
The introduction of referral management was not associated with a reduction in the outpatient attendance rate or attendance rate ratio in any group. Despite larger budgets, RMCs were no more effective in reducing the attendance rate than internal peer-review approaches. This observational study from one region showed that referral-management schemes are poor value. However, these findings need confirmation from larger randomised studies using robust methods.
