Effect of NHS reforms on general practitioners' referral patterns.

OBJECTIVE--To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991. DESIGN--Prospective collection of data on general practitioners'' referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2). SETTING--10 fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS--Patients referred to consultant outpatient clinics. RESULTS--After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders. CONCLUSIONS--Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners'' referral behaviour.     

General practitioners' referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics.

There has been much concern about the wide variations in general practitioners'' referral rates and the consequent implications for cost and quality of care. This has led to a call to evaluate the appropriateness and effectiveness of referrals. A collaborative audit of referrals to outpatient clinics was conducted by 127 general practitioners in 33 practices in the Oxford region. Records were kept of 18,754 referrals, which included data on diagnoses and reasons for referral. Overall, 6553 (35.4%) of the referrals were for particular treatments or operations and a further 6475 (34.9%) were for specific investigation or diagnosis. Advice on management was the main reason for referral in 2656 (14.3%) cases, and in 1719 (9.3%) cases the general practitioners wanted the consultants to take over managing their patients. Reassurance of either the general practitioner or the patient was recorded as the main reason in only 762 (4.1%) referrals. There seems to be scope for rationalising the referral process. A programme with three stages for evaluating referrals to outpatient clinics is recommended.     

Relation between general practices' outpatient referral rates and rates of elective admission to hospital.

OBJECTIVE--To examine the variation in rates of admission to hospital among general practices, to determine the relation between referral rates and admission rates, and to assess the extent to which variations in outpatient referral rates might account for the different patterns of admission. DESIGN--A comparison of outpatient referral rates standardised for age and sex and rates of elective admission to hospital for six specialties individually and for all specialties combined. SETTING--19 General practices in three districts in Oxford Regional Health Authority with a combined practice population of 188 610. MAIN OUTCOME MEASURES--Estimated proportion of outpatient referrals resulting in admission to hospital, extent of variation in referral rates and admission rates among practices, and association between admissions and outpatient referrals. RESULTS--Patients referred to surgical specialties were more likely than those referred to medical specialties to be admitted after an outpatient referral. Overall, the estimated proportion of patients admitted after an outpatient referral was 42%. There were significant differences among the practices in referral rates and admission rates for most of the major specialties. The extent of systematic variance in admission rates (0.048) was similar to that in referral rates (0.037). Referral and admission rates were significantly associated for general surgery; ear, nose, and throat surgery; trauma and orthopaedics; and all specialties combined. For most specialties the practices with higher referral rates also had higher admission rates, casting doubt on the view that these practices were referring more patients unnecessarily. CONCLUSION--Rates of elective admission to hospital vary systematically among general practices. Variations in outpatient referral rates are an important determinant of variations in admission rates.     

Consultants' workload in outpatient clinics.

The impact on hospital resources of variability in referral rates among general practitioners was of concern throughout the 1980s. The overall number of patients referred to outpatient clinics, however, has increased only slowly since the NHS began; in contrast, the number of new outpatients seen by each hospital consultant has declined appreciably. Ironically, despite this decline, further increasing the number of consultants in now being presented as a solution to the demand for outreach clinics in general practice.     

Specialist outreach clinics in general practice.

OBJECTIVES--To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists'' and general practitioners'' views on outreach clinics. DESIGN--Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. SETTING--50 hospitals in England and Wales. SUBJECTS--50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. MAIN OUTCOME MEASURES--Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. RESULTS--28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. CONCLUSIONS--Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Purchasing for all: an alternative to fundholding.

OBJECTIVE--To evaluate general practitioner participation in a district health authority''s purchasing work. DESIGN--Questionnaire study of 131 Hackney general practitioners and 33 senior health service managers; review of the minutes of 28 meetings of the Hackney General Practitioners'' Forum and the contract between City and Hackney Health Authority and the St Bartholomew''s NHS Trust. SETTING--Hackney General Practitioners'' Forum. MAIN OUTCOME MEASURES--General practitioners'' and managers'' perceptions of how representative and effective the general practitioners'' forum is; proportion of new quality targets and service developments contributed by general practitioners; main issues discussed by the forum and impact on district health authority policy. RESULTS--99 (76%) general practitioners and 27 (82%) managers responded. Both groups perceived the forum as representative. 92% (24/26) of the managers thought the forum was effective but only 74% (70/95) of general practitioners did so, largely because some doubted that the forum was listened to 75% (103/138) of quality targets and 55% (16/29) of service developments planned in the 1993-4 contract were contributed by general practitioners. They also lobbied successfully for more resources for urology and community mental health services. CONCLUSIONS--Input into commissioning via a general practitioners'' forum can be both representative and effective. General practitioners need to work closely to achieve a consensus and those involved need administrative support. The relation between general practice and public health medicine needs to be strengthened.     

Contribution of a general practitioner hospital: a further study.

OBJECTIVE--To audit the workload of a general practitioner hospital and to compare the results with an earlier study. DESIGN--Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). SETTING--A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. PATIENTS--20,000 Patients living in the Brecon area. RESULTS--1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). CONCLUSIONS--The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. IMPLICATIONS--General practitioner hospitals should have a future role in the NHS.     

Positive and negative factors in defensive medicine: a questionnaire study of general practitioners.

OBJECTIVES--(a) To investigate defensive medical practices among general practitioners; (b) to compare any such practices with general practitioners'' understanding of certain aspects of the terms of service and medical negligence and practitioners'' concerns about the risk of being sued or having a complaint lodged. DESIGN--Postal questionnaire survey. Each questionnaire was followed by a reminder. SUBJECTS--500 systematically selected general practitioners on the membership list of the Medical Defence Union. MAIN OUTCOME MEASURES--Answers to questions on defensive medical practices, understanding of certain aspects of the terms of service and medical negligence, and concerns about the risk of being sued or having a complaint lodged. RESULTS--300 general practitioners returned the questionnaire (response rate 60%). 294 (98%) claimed to have made some practice changes as a result of the possibility of a patient complaining. Of the defensive medical practices adopted, the most common (over half of doctors stating likely or very likely) seemed to be increased diagnostic testing, increased referrals, increased follow up, and more detailed patient explanations and note taking. Respondents practised defensive medicine as a possible consequence of concerns about the risks of being sued or having a complaint lodged. This association was particularly strong for negative defensive practices. Defensive medical practice did not correlate with any misunderstanding about the law of negligence or the general practitioners'' terms of service. CONCLUSIONS--General practitioners are practising defensive medicine. Some defensive practices such as increased patient explanations or more detailed note taking are clearly beneficial. However, implementing the findings of the Wilson report may increase negative defensive medical practices.     

Can telemedicine be used to improve communication between primary and secondary care?

OBJECTIVE: To test feasibility and acceptability of teleconferencing routine outpatient consultations. DESIGN: Exploratory trial of teleconferenced outpatient referrals of general practitioners. SETTING: An inner city teaching hospital and surrounding general practices. SUBJECTS: Six general practices linked to hospital outpatient clinics. MAIN OUTCOME MEASURES: Levels of participants'' satisfaction measured with self administered questionnaires. RESULTS: 54 teleconsultations were performed in 10 different specialties. Few serious technical problems were encountered, and high levels of satisfaction with the consultations were reported by patients, hospital specialists, and general practitioners. CONCLUSIONS: Teleconferenced consultations for routine outpatient referrals with joint participation of general practitioner were feasible. These may have an important potential benefit for improving communication between primary and secondary care.     

Comparison of immunisation rates in general practice and child health clinics.

OBJECTIVE--To compare immunisation uptake rates in general practice surgeries and community child health clinics. DESIGN--Cohort study using data from a computerised child health system. SETTING--Four health districts of North East Thames Regional Health Authority. SUBJECTS--3616 children born January to March 1990 and resident in the four districts at the end of January 1991. MAIN OUTCOME MEASURES--Immunisation uptake rates at 10-12 months of age, age at immunisation, scheduling performance at the two locations, and odds ratios of outstanding immunisations. RESULTS--80% of children registered at general practices had completed their third dose of pertussis immunisation compared with 68% of those at health clinics. Median ages at the third dose were 24 weeks and 29 weeks at the two locations respectively. Scheduling was more effective at general practice surgeries. Unscheduled immunisations were more likely to be given after the recommended age. Overall, children resident in rural and suburban areas had greater uptakes than those in inner cities. Odds ratios for not being fully immunised among children registered at health clinics were 1.4 times those among children immunised in general practice and 3.0 times greater among children resident in inner cities than among those in rural and suburban districts. Children who moved into a district, however, were no less likely to be fully immunised than children who were born there. CONCLUSIONS--The immunisation uptake rate was better in general practices than in child health clinics in both inner city and rural and suburban areas. Uptake may be increased with additional support to enable general practitioners to undertake immunisations, especially in inner cities.     

Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease.

Case notes of 1113 consecutive new patients referred to a consultant ophthalmologist at a district general hospital were reviewed to determine the source and efficacy of referrals and the current screening practices of general practitioners and ophthalmic opticians. General practitioners initiated referral in 546 cases (49%) and ophthalmic opticians referral in 439 (39%). Visual loss or visual disturbance was the most important single reason for referral (345 cases; 31%), followed by suspected glaucoma (145 cases; 13%), abnormalities of binocular vision (140; 12.5%), disorders of eyelids or ocular adnexa (127; 11%), and red eye (86; 8%). General practitioners referred many more patients with disorders of the eyelids and adnexa and ophthalmic opticians many more patients with suspected glaucoma. Ophthalmic opticians were far more likely than general practitioners to refer patients with suspected glaucoma correctly. A total of 180 patients (16%) were referred from ocular screening, in 149 cases by ophthalmic opticians and in 10 by general practitioners. Seventy patients had glaucoma or incomplete features of glaucoma, all of them referred by ophthalmic opticians. Of eight diabetic patients referred by ophthalmic opticians, three had asymptomatic disease and in two diabetes was diagnosed as a result of ocular screening. No patient was referred for asymptomatic diabetic retinopathy from screening by general practitioners. Ophthalmic opticians were more likely than general practitioners to diagnose retinopathy requiring photocoagulation. Use of a community based service to screen for glaucoma could save unnecessary consultant outpatient appointments. A similar service could facilitate detection of diabetic retinopathy at a stage when treatment is most effective.     

Referrals from general practice to hospital outpatient departments: a strategy for improvement.

OBJECTIVE--To determine the appropriateness of referrals from general practice to hospital outpatient departments. DESIGN--Prospective audit of referrals from a group practice over one year. SETTING--Six handed practice in a southern coastal town. SUBJECTS--All patients referred during the study period for whom a copy of the referral letter was available. MAIN OUTCOME MEASURES--The investigations carried out by the consultant that led to the diagnosis; the diagnosis reached; and the management. RESULTS--Of roughly 3000 patients referred during the year, 277 with various skin and soft tissue disorders could probably have been managed solely by the general practitioner. Referrals for cryotherapy (96 in this series) and diabetes (19) could probably also have been avoided by specialist training of the general practitioner. In addition, in cases of haematuria and prostatic hypertrophy (34 and 22 referrals) substantial time could have been saved for both the patient and the consultant had the general practitioner supplied the results of relevant investigations. Probably the most important outcome was the model that the study offered for other general practitioners to improve the appropriateness of referrals. CONCLUSION--This approach to determining the appropriateness of referrals benefits the general practitioners, the consultant, and the patient.     

The effect of deprivation on variations in general practitioners' referral rates: a cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire.

OBJECTIVE: To determine the effect of deprivation on variations in general practitioners'' referral rates using the Jarman underprivileged area (UPA(8)) score as a proxy measure. DESIGN: Cross sectional survey of new medical and surgical referrals from general practices to hospitals (determined from hospital activity data). SETTING: All of the 183 general practices in Nottinghamshire and all of the 19 hospitals in Trent region. MAIN OUTCOME MEASURES: The relation between the referral rates per 1000 registered patients and the practice population''s UPA(8) score (calculated on the basis of electoral ward), with adjustment for the number of partners, percentage of patients aged over 65 years, and fundholding status of each practice. RESULTS: There was a significant independent association between deprivation, as measured by the UPA(8) score, and high total referral rates and high medical referral rates (P < 0.0001). The UPA(8) score alone explained 23% of the total variation in total referral rates and 32% of the variation in medical referral rates. On multivariate analysis, where partnership size, fundholding status, and percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively. CONCLUSION: Of the variables studied, the UPA(8) score was the strongest predictor of variations in referral rates. This association is most likely to be through a link with morbidity, although it could reflect differences in patients'' perceptions, doctors'' behaviour, or the use and provision of services.     

The extent of the two tier service for fundholders.

OBJECTIVE--To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners. DESIGN--Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995. SETTING--District health authority in south-west England. SUBJECTS--10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients. MAIN OUTCOME MEASURES--Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times. RESULTS--In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5. CONCLUSIONS--Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.     

Communication of results of necropsies in north east Thames region.

OBJECTIVE--To evaluate the adequacy of reporting of results of necropsy to referring clinicians and to general practitioners. DESIGN--Questionnaire survey of referring clinicians and general practitioners of deceased patients in four districts in North East Thames region. Patients were selected by retrospective systematic sampling of 50 or more necropsy reports in each district. SETTING--One teaching hospital, one inner London district general hospital, and two outer London district general hospitals. PARTICIPANTS--70 consultants and 146 general practitioners who were asked about 214 necropsy reports; coroners'' reports were excluded. MAIN OUTCOME MEASURES--Time taken for dispatch of final reports after necropsy, consultants'' recognition of the reports, general practitioners'' recognition of the reports or of their findings, and consultants'' recall of having discussed the findings with relatives. RESULTS--Only two hospitals dispatched final reports including histological findings (mean time to dispatch 144 days and 22 days respectively). 42 (60%) consultants and 83 (57%) general practitioners responded to the survey. The percentage of reports seen by consultants varied from 37% (n = 13) to 87% (n = 36); in all, only 47% (39/83) of general practitioners had been informed of the findings by any method. Consultants could recall having discussed findings with only 42% (47/112) of relatives. CONCLUSIONS--Communication of results of necropsies to hospital clinicians, general practitioners, and relatives is currently inadequate in these hospitals. IMPLICATIONS AND ACTION--A report of the macroscopic findings should be dispatched immediately after necropsy to clinicians and general practitioners; relatives should routinely be invited to discuss the necroscopic findings. One department has already altered its practice.     

Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs.

OBJECTIVE--To compare general practitioners'' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991. DESIGN--Analysis of prescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992. SETTING--Oxford region. PARTICIPANTS--Three dispensing fundholding practices; five non-dispensing fundholding practices; and seven non-dispensing, non-fundholding practices. MAIN OUTCOME MEASURES--Percentage change in net cost of ingredients, number of items prescribed, average cost per item, and proportion of generic drugs prescribed after NHS reforms. RESULTS--Prescribing costs increased in all practices in the six months after the reforms. The net costs of ingredients increased among dispensing fundholders by 10.2%, among non-dispensing fundholders by 13.2%, and among non-fundholders by 18.7%. The number of items prescribed also increased in all three groups (by 5.2%, 7.5%, and 6.1% respectively). The increase in average cost per item was 4.8% for dispensing fundholders, 5.3% for non-dispensing fundholders, and 11.9% for non-fundholders. Dispensing fundholders increased the proportion of generic drugs prescribed from 26.9% to 34.5% and non-dispensing fundholders from 44.5% to 48.7%; non-fundholders showed no change (47%). Five of the eight fundholding practices made savings in their drugs budgets at the end of the first year of fundholding (range 2.9-10.7%; the three other practices overspent by up to 3.6%). All non-fundholding practices exceeded their indicative prescribing amounts (range 3.2-20.0%). CONCLUSIONS--Fundholding has helped to curb increases in prescribing costs, even among dispensing general practitioners, for whom the incentives are different. Indicative prescribing amounts for non-fundholding practices do not seem to have had the same effect.     

Open access to orthopaedic appliances for general practitioners.

A clinic to which general practitioners can refer patients for some types of orthopaedic appliances was opened in North Clwyd in 1983. During 1985, 956 patients were referred by 82 general practitioners; 860 patients received an appliance, and the average waiting time was less than five weeks. Most referrals were for soft collars (44%), lumbar sacral supports (30%), and dorsilumbar supports (7%). Thirty eight patients failed to attend, 54 declined an appliance, and four referrals were considered to be inappropriate. A few patients were subsequently referred to consultant outpatient clinics, 22 for physiotherapy and 34 were referred simultaneously to the open access clinic. The referral rates for general practitioners with access to community hospitals were low. Such an arrangement merits wider consideration.     

Avoidable referrals? Analysis of 170 consecutive referrals to secondary care.

OBJECTIVE--To determine appropriateness of referrals from primary care to secondary care. DESIGN--Retrospective evaluation of appropriateness of referrals from a single-handed general practice: evaluations carried out independently by referring doctor and by second general practitioner who worked in same area and had access to similar secondary care services. SUBJECTS--168 referrals made between 1 October 1990 and 31 March 1991 and followed up for up to 12 months by matching with available information on outcome of episode of care. MAIN OUTCOME MEASURES--Appropriateness of referral and reasons for inappropriate referrals. RESULTS--110 referrals were agreed to be appropriate and 58 were considered avoidable. The reason for 32 of the inappropriate referrals was lack of resources: 10 were due to lack of information (mainly failure of hospitals to pass on information to general practitioner), nine were due to a deficient primary health care team; five were due to insufficient use of home care nurses, three were due to absence of direct access to day hospital, and five were due to lack of access to general practitioner beds or other facilities. Most of the remaining 26 avoidable referrals were because available resources had not been fully used, because recognised management plans had not been followed, or because of lack of skills to perform certain procedures. CONCLUSIONS--Many theoretically avoidable referrals were due to managers'' and politicians'' decisions about allocation of resources, but some inappropriate referrals could be avoided by assessment of general practitioners'' needs for further knowledge and skills.