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Referral management principles

March 2007

The Central Consultants and Specialists Committee and General Practitioners Committee have produced the following joint document, which aims to set out the key guiding principles of referral management schemes.

This document aims to set out the key guiding principles for the establishment, objectives and continuing progress of referral management schemes. It is intended to cover all such schemes including Clinical Assessment and Treatment Services (CATS), and Integrated Clinical Assessment and Treatment Services (ICATS) and the like. The term referral management scheme should be taken to apply to all arrangements that incorporate any intermediary level(s) of triage, assessment and treatment between traditional primary and secondary care including paper-based screening systems (or their electronic equivalent).

Guiding principles
1. The gold standard for referrals should be the traditional GP to consultant referral.

2. Referral management’s prime purpose is to improve the patient care pathway to deliver tangible benefits for patients. It should not lengthen or complicate the patient journey. It must not be simply to save money, though it can and should consider cost-effective use of resources.

3. Referral management schemes must only be introduced following discussion between a broad representative body of primary and secondary care doctors, managers and, where appropriate, other health professionals and patients. The discussions must demonstrate real engagement and agreed common outcomes.

4. Referral management schemes should not cut across patient choice principles. They should be transparent; patients should be fully informed about the process that will apply to their referral, with advice about the possible outcomes and the implications for their care.

5. Referral management schemes must recognise and support the value of specific referral by a patient’s doctor to a particular consultant or team for clinical reasons. They must not weaken the principle of clinician-to-clinician referral where it is clinically indicated.

6. Any system of reviewing referrals must take proper account of the expert opinion of primary and secondary care clinicians and should only be undertaken by properly-qualified clinical professionals. Referrals should be based on the expert views of GPs, consultants and other specialists.

7. There must be absolute clarity on responsibilities and accountability in any referred cases. The referral management process should take account of the GMC’s “Duties of a Doctor”.

8. Any referral management scheme must include timely and appropriate consultation with and communications to all professionals and patients that could be affected.

9. Referral management schemes should work at the interface of primary and secondary care, helping to integrate rather than separate the two. In doing so they should demonstrably facilitate collaboration between primary and secondary care clinicians. Any assessment and treatment services provided at this interface should be multi-disciplinary in nature, drawing in expertise already available in the locality.

10. Any referral management system must have robust clinical governance arrangements and audit in place with strong leadership and clear accountability.

11. Consideration of any referral management scheme must assess the impact on existing services as well as the potential benefits of the scheme itself.

12. Any referral management system should offer an educational element, including an appropriate programme of staff training.

Objectives and functions
The objectives and functions of a referral management scheme should be clearly defined in a key document so that there is no confusion about its place in the GP/consultant referral process and to help guide it in achieving its strategic objectives.

A referral management scheme’s objectives and functions may include;

1. Providing expert multi-disciplinary opinions for patients referred by GPs by offering an alternative to direct referral to an outpatient consultant clinic.

2. Screening for important conditions and referring patients onwards as appropriate.

3. Directing patients to appropriate services for investigation or referral back to GP.

4. Conducting clinical assessments, organising diagnostic investigations, providing advice and treatment.

5. Agreeing and testing integrated care pathways (ICPs) which must be built on evidence-based guidelines with locally agreed protocols and quality measures.

6. Facilitating referral where necessary, to other primary or secondary care services with agreed referral processes in place which are understood by all.

7. Supporting the development of robust systems for monitoring and clinical audit.

Outline of a model process for establishing a referral management scheme
The following provides a generic outline of the process that should ideally be followed in establishing a referral management scheme.

1. Schemes which are new in nature, to a local healthcare economy, or to a clinical area/speciality should be piloted before being permanently rolled out and their success formally audited. GPs and consultants should be actively involved in and integrated into the piloting and auditing process. Mechanisms should be established to learn from current best practice.

2. A project team consisting of those clinicians and managers responsible for developing and delivering the scheme should be established and a project lead appointed. The project team must include patient representatives and representatives from the local GP and consultant community.

3. Prior to piloting the schemes, the project team should identify all the available evidence (such as NICE guidance, and speciality-specific accepted standards of care). Clinical guidelines and protocols must be based on that evidence and they must be agreed between the clinicians that will be involved in or affected by the scheme. This approach should also be followed to test the existing way of working.

4. Before implementing the scheme, the project team must agree a process of consultation and communication with, and seeking advice from, all stakeholders. This should include liaison with patient and the relevant clinical networks. The consultation should encompass the safety, necessity and general desirability of the scheme to the local health economy as well as the practicalities of implementation.

5. As part of this process, meetings of key stakeholders, including, clinicians, patient representatives, nurses, allied health professionals etc should be organised and the views expressed formally fed back to the project team.

6. Staff communication strategies need to be agreed and implemented to ensure that all staff involved fully understand the workings of all aspects of the scheme, but particularly those affecting the clinical situations in which they will work.

7. An appropriate programme of staff training needs to be organised and put in place, in line with the operation and details of the scheme.

8. Where possible, a set of activity and audit data for collection by the CATS staff and benchmarking data should be agreed.

9. Once the scheme is in operation, patients need to be tracked along their treatment pathways to manage patient flow and to identify any emerging problems (logistical, clinical or other).

10. It is absolutely essential that, as the scheme develops and as referral patterns change, all those involved continue to promote the integration and coordination of services across primary and secondary care providers through regular, formalised liaison. All available local clinical expertise should be brought into play, used to optimal effect and not simply substituted for. If capacity is freed up as result of the scheme, it should be re-integrated, not wasted.

Where such schemes are open to tendering for possible providers, all potential providers, including the local NHS must be able to tender on an equal basis, which takes account of the wider aspects of provision of healthcare in a local health economy, and the outcome must be open to scrutiny to ensure fairness.