1. Variability in GP Referral Rates to Secondary Care Adam Frosh FRCS(Ed), FRCS(ORL-HNS) Consultant ENT Surgeon

2. Background 1989 White paper Working for Patients - 20-fold variation in GP referral rates to hospital Crombie and Fleming estimated that for a practice population of ~2000 patients, the hospital expenditure (at 1981 prices) associated with the lowest and highest rates of referral were £40,000 and £408,000, a 10-fold difference

3. Questionable Assumptions Increases in referral rates are caused directly and solely by GPs changing their referral behaviour. An increase in referrals will represent an increase in inappropriate referrals High referral rates reflect inefficiency, poor practice or failure to treat adequately in Primary care

4. Rise in the number of GP consultations taking place per patient, per year 1995 3.9 2007 5.416 Hippisley-Cox, J. Jumbu, G (2008). Trends in Consultation Rates in General Practice 1995 to 2007: Analysis of the QRESEARCH database. The NHS Information Centre.

5. Difficulties Appropriateness of a referral difficult to define Threshold for referrals do not just depend on rigid clinical criteria Perhaps – how we can help each other in the referral process most important issue

6. Is Variability of Referral Rates Important? Appropriateness –No association yet seen connecting referral rates to appropriateness Outcomes –Literature is poor

7. Analysis by C. O’Donnell 2000 (i) patient characteristics; (ii) practice characteristics; (iii) GP characteristics; and (iv) access to specialist care

8. Practice Characteristics Practice size –7 papers. Conflicting results Geographical location –Some increase in referral activity with closeness of hospital from the practice Fundholding –Only explains 5% variation

9. GP Characteristics No relationship was found between referral rates and age of GP, years of experience or membership of the RCGP in some UK studies GPs with a specialist interest in ENT and ophthalmology had high referral rates to these specialities, which persisted after adjusting for case mix –Reynolds GA, Chitnis JG, Roland MO. General practitioner outpatient referrals: do good doctors refer more patients to hospital? Br Med J 1991; 302: 1250–1252

10. Access to Specialist Care Increasing consultant numbers per area increases referral rates –Roland M, Morris R. Are referrals by general practitioners influenced by the availability of consultants? Br Med J 1988; 297: 599–600. The opening of a district general hospital led to an increase in referral rates for those specialities now providing a local consultant-based service –Noone A, Goldacre M, Coulter A, Seagroatt V. Do referral rates vary widely between practices and does supply of services affect demand? A study in Milton Keynes and the Oxford region. J R Coll Gen Pract 1989; 39: 404–407.

11. Influence of Health Initiatives and Policies on Referral Rates –Practice based commissioning; –Local PCT demand management targets for general practice; – Care pathway reforms/care closer to home; –Introduction of Clinical Assessment Services (CAS) and Referral Management Services; – Increase in availability of non-consultant providers e.g. GPs with special interests (GPwSIs) and nurse- led clinics.

12. Reasons for Referral to Secondary Care Diagnosis Investigation Advice on treatment Specialist treatment Second opinion Reassurance for the patient Sharing the load, or risk, of treating a difficult or demanding patient Deterioration in general practitioner-patient relationship, leading to desire to involve someone else in managing the problem Fear of litigation Direct requests by patients or relatives

13. Changing Secondary Care Practice and Systems Restricting consultant to consultant referrals Hospital waiting list management eg restriction of referrals at peak times Discharging DNA’s generating new referrals Early discharge from hospital 18 week target increasing supply for demand of referrals GP visit for aftercare from independent healthcare centres

14. Changing Primary Care Practice and Systems Increasing patient access to primary care increases referral rates to secondary care eg increases need for 2 nd opinion –Coulter, A (1998). Managing demand at the interface between primary and secondary care British Medical Journal 316:1974-1976 QOF, and GMS contracts increase referrals –Srirangalingam U. Sahathevan S. K. Lasker S. S. Chowdhury T. A. (2006). Changing pattern of referral to a diabetes clinic following implementation of the new UK GP contract. British Journal of General Practice. 56(529):624-6, NICE guidance Rise of multidisciplinary referrals –Practice nurses –Opticians Rise of defensive medicine –Salaried GPs –Locums –Part time working –Erosion of personal lists –Extended opening hours –Walk in centres Summerton, N (1995). Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. British Medical Journal 310:27-29

15. Choose and Book Increased availability and awareness of services Rejected referrals can generate new referrals Inaccurate DOS may create re-referrals

16. PBR Increased accuracy in coding increases apparent referral rates Perverse incentives for trusts to miscode f/u as new patient

17. Changes to the Population Ageing population living with diseases –hearing loss –Heart disease –Diabetes –COPD –CVA Obesity New technologies and medical advancement Information age Increasing sense of patient entitlement

18. Conclusions Highly complex area. No research into the relationship between national policies and referral rates Variations between gp practices’ referral patterns and rates remain largely unexplained. Patient, practice and gp characteristics account for less than half of observed variation Impact of social class is not clear-cut No one variable or group of variables appears to be a predictor of variation No relationship found between referral rates and age of GP, years of experience or membership of the RCGP Conflicting evidence about the relationship between practice size and variation in referral rates

19. Conclusions 2 Vary from PCT to PCT, GP practice to GP practice and even GP to GP Unique combination of factors Timing of impact of any one factor – for example of choose & book – will not necessarily have immediate effects NHS complexity – local health community factors PCT-commissioned referral analysis schemes Analysis by specialty, rather than a focus purely on average GP referral to hospital figures

20. And finally…. Simply increase the unmet need!

21. Primary care pathway for Sleep disorders/ Sleep apnoea BMI >40 ( consider referral to specialist bariatric services) Epworth Sleepiness Scale (ESS) > 15 Comorbid disease (IHD, TIA, CVA, DM, respiratory problems, cardiac problems (heart failure, uncontrolled hypertension, head injury before onset of symptoms) Excessive and Intrusive Sleepiness (EIS) whilst driving Sleep violence/ unsocial activities REM related symptoms (cataplexy, sleep paralysis, sleep onset dreams) Vigilance critical activity include commercial driving, pilots. Any obvious abnormality of nose and throat Any strong suspicion of specific sleep disorder e.g Restless leg syndrome

22. ENT Treatments for Snoring Relieve obstruction/restriction to nasal airflow Excise large tonsils UVPP

23. ENT in Primary Care GPwSI ENT CATS Microsuction Impedance tympanometry Pure tone audiometry Thorough understanding of medical treatments of rhinitis Minor operative procedures eg to earlobe Direct access to physiotherapy services for dysequilibration

24. Regulation of Referrals from Primary Care to ENT Recurrent tonsillitis Glue ear Hearing loss

25. Thresholds of benefit –Those procedures which do work –Those which don’t work –Those procedures which work proportionately better above a certain threshold eg tonsillectomy for tonsillitis

26. Honesty to Patients About Unfunded Procedures Admit to patients there are insufficient funds Be honest about the evidence for a treatment irrespective of its funding status Refrain from dismissing all unfunded treatments as those which don’t work

27. Parachute Study