All GP referrals should be subject to clinical peer review, says NHS England

GPs will be expected to discuss with other GP colleagues their decision to refer any new patients to hospital, as part of a push by NHS England to curb inappropriate referrals to secondary care.

Guidance issued by NHS England to clinical commissioning groups (CCGs) in May stated that all areas of the country should have a system in place from September 2017 to ensure that all new GP referrals are subject to clinical peer review.

A spokesman for NHS England told The BMJ that around half of CCGs already had a peer review process in place and that it was up to the other half to follow suit. NHS England emphasised that any system should not be “established as an approval process and the referring GP retains responsibility for the patient and makes the final decision.”

The spokesman said that the process should be informal, akin to a “chat over a cup of tea.” “We’re not being prescriptive—it is between CCGs and GPs to work out what’s best for them,” he said. “The issue repeatedly reported to us is that patients are turning up to appointments they don’t need. This is taking up hospital time, and [this is] aimed at reducing that.”

The guidance was sent to CCGs in May in a document called Elective Care High Impact Interventions: Clinical Peer Review, which was seen by Pulse magazine.1Pulse reported that the document mentioned “significant additional funding” for commissioners to establish GP peer review schemes this year. But NHS England said that it would not share the document with the media.

NHS England has been promoting the idea of referral peer review for some time, but this is the first time it has said that it is mandatory. NHS England highlighted a King’s Fund report that looked at various ways to reduce referrals,2 including the use of referral management centres and peer review. The report said that peer review can increase the likelihood of GPs referring when necessary, can improve the quality of referral letters, and can help GPs direct referrals to the most appropriate setting. However, it found that peer review may not always change GPs’ behaviour.

An investigation by The BMJ earlier this year found that many CCGs in England were already committing millions of pounds to schemes designed to screen GP referrals to specialist services.3 But the investigation found that only a small fraction of these were being fully evaluated in terms of their cost effectiveness.

Andrew Green, clinical lead for the BMA’s general practitioners committee, said that he was sceptical of the process, which he said would increase workload. He said, “I wish that NHS England put a 10th of the effort it expends on reducing pressure on hospitals into reducing pressure on GPs, which is the area of the health service with the biggest growth in workload.

“It is important to be aware of the lost opportunity costs of schemes like this, if we assume an hourly weekly meeting that would be equivalent to removing 1000 GPs from the English workforce—GPs we don’t have.”

Martin Marshall, vice chair of the Royal College of General Practitioners, said, “Reviewing referrals is an integral and constructive part of general practice, and we usually do this to ensure our patients are getting the best possible care.”

But he added, “When the main purpose is to make efficiency savings by reducing the number of referrals, we have major concerns. There is little or no evidence that referral management schemes are cost effective, and they can damage patient care.”