Referral management plan - NHS e-Referral Service

Hospital referral rates in England have increased significantly over recent years, resulting in the management of referrals becoming a high priority for many local health communities as a means of controlling their capacity and budgets. In 2010 The King's Fund issued a report ‘Referral management - Lessons for success’ which lists ways in which clinical commissioners might ensure referral management strategies improve quality and make savings.

The King's Fund report stated that:

"There was evidence that full-scale referral management centres are unlikely to present value for money and some of the new clinical triage and assessment services might add to rather than reduce costs."

"Instead, a referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is mostly likely to be both cost and clinically effective."

When planning a referral management scheme, there are 7 principles which should be followed. These are to:

• treat patients as individuals with needs and concerns at very uncertain times of their lives
• promote patient choice
• recognise the management of referrals as a clinical skill
• maintain professional autonomy and responsibility for patients and their referrals
• deliver quality and efficiency
• adhere to NHS data quality standards
• deliver financial savings – but not at any price

Any referral management plan should include the following 6 steps to support referrers:

1. Develop and maintain own professional skills, knowledge and experience
2. Use external resources and knowledge bases to check referral criteria or alternative treatment options
3. Arrange peer review by colleagues (for example within a referring practice or a clinical commissioning group)
4. Seek advice and guidance from more qualified clinician
5. Request formal assessment/triage by a specialist clinician
6. Encourage rejection of inappropriate referrals by provider clinicians (for example consultants and AHPs)

e-RS can support all the six stages of referral management listed above.

Stage 1: Professional knowledge

It is the responsibility of commissioning organisations to ensure that adequate service provision is made for the clinical needs of patients and that community services exist which deliver cost and clinically effective alternatives to hospital-based services.

These services should be made available on e-RS to provide referrers with an easy way of identifying what is available locally.

It is the responsibility of referring clinicians to ensure that they are up to date with available treatment options and that they know the conditions that are best dealt within differing care settings.

Clinicians should use e-RS to:

• see what services are available in the community
• monitor outcomes of referrals
• note responses from advice and guidance requests
• note and act on rejection advice
• update knowledge based on advice in service details or links to external guidance

Stage 2: External resources

e-RS allows links to external guidance via hyperlinks. For example:

• national guidance - such as NICE
• map of medicine
• local hospital protocols
• local and national referral forms - that check referral criteria have been met

e-RS contains several search methods (for example using clinical terms) to find appropriate services and identify referral criteria.

Stage 3: Peer review

Peer review should ideally take place within the referring organisation by clinicians meeting regularly to discuss individual cases.

Smaller practices should consider sharing or pooling skills and resources to assess referrals.

Advice and guidance can be used to allow referral assessment by clinicians in the same or local organisations.

Stage 4: Advice and guidance

e-RS supports the concept of one clinician asking for advice from another and receiving a reply.

Advice and guidance should be used where genuine questions need to be asked regarding referral options or where complex, alternative treatment pathways exist.

Referrers should see this as a tool to improve their knowledge base and avoid the need to seek advice for similar conditions in the future.

Stage 5: Clinical assessment services

Clinical assessment services:

• should be aimed at determining the correct clinical pathway for the patient, where the referrer is unsure or where the options are complex
• should provide added clinical value to the referral pathway
• should minimise lengthening of referral to treatment times and be provided for specialties where proven benefits are likely
• must be carried out by clinicians who are authorised and suitably skilled to be able to deviate from agreed protocols, based on individual patient needs, if required
• should, wherever possible, involve a personal interaction between the provider clinician and the patient or their referring clinician
• should take place at a pre-arranged time that the patient is aware of
• should address the concerns and uncertainties of patients

Stage 6: Rejection of referrals

Provider clinicians (for example consultants or AHPs) must be empowered to reject clinically inappropriate referrals but must be mindful of the effect of rejection on patients and the reputation of fellow professionals.

Provider clinicians should feed-back (via commissioning groups) the details of referrers who are consistently referring inappropriately.

Redirection should be considered as an alternative to rejection where the referral is appropriate, but where a more suitable clinic or service exists.

Referring clinicians should accept feedback and referral outcomes as a positive learning experience.

Effects on patients should always be considered. For example, it must be in a patient’s best interests to reject.

Below are the responsibilities of different organisations involved in developing a referral management plan

Responsibilities of clinical commissioning groups (CCGs)

CCGs should:

• prevent unnecessary and expensive referral management schemes
• support education and training of referrers
• promote benefits of effective referral management tools (for example e-RS)
• ensure adequate local (community) service provision is available as an alternative to hospital services via e-RS
• promote patient choice and professional autonomy/responsibility for referrals
• make provision for peer review and advice/guidance

Responsibilities of referrers

Referrers should:

• maintain professional skills and education
• understand local service provision
• use e-RS as a clinical tool
• support and understand patients’ rights to choice
• be prepared to ask for advice from colleagues
• meet regularly with colleagues to discuss referrals
• audit referral outcomes and learn from feedback

Responsibilities of service providers

Service providers should:

• ensure that all services are directly bookable on e-RS with adequate appointment capacity to match demand
• ensure that the e-RS directory of service entries is accurate and contain appropriate information to support referrers
• provide an advice and guidance facility
• encourage all clinicians to review referrals on line and provide feedback where appropriate
• empower clinicians to reject clinically inappropriate referrals
• accept all clinically appropriate referrals

Responsibilities of health communities

Local health communities should come together to:

• develop local referral protocols
• ensure that clinicians are involved at all stages of planning a referral management scheme
• develop education, training and support groups
• seek feedback from patients on their experiences of the referral process
• make efficiency savings for the NHS - but not at the expense of quality