If that isn’t enough to cause sleepless nights, he said his PCT

“recently audited all our admissions through A&E and were informed that up to 40% of admissions could have been managed in the community. Now OK, we’ve all heard headline stuff like this before, and no surprises that the majority were falls (patients who were largely sent back home with little change). But even if the number was 10% it is still huge in both numbers and pounds spent.”

Gasp!

This is a shocking indictment on all levels. An effective falls prevention strategy across health and social care should go a long way to reducing this wasteful activity which can wreck the lives of elderly people for no purpose as most are discharged untreated. So why are these policies not in place and being followed? If health and social care professionals at the grass roots cannot do something about this and quickly, one has to wonder what chance the proposed new arrangements will have? He says it is “time to step up to the plate to curb referral over-activity”. Are people up to it? They cannot afford not to be. Read the full story here http://www.pulsetoday.co.uk/story.asp?storycode=4127033&cid=In-depth_1_100910&sp_rid=NDE0NjI3MzcxNgS2&sp_mid=35778856

As Pulse summarised the situation today:

“GP referrals to secondary care appear to be accelerating again, with the latest figures from the Department of Health showing a 6% year-on-year rise in the first quarter of 2010/11. DH figures on outpatient referrals and attendances, published today, show the number of GP referrals made from April to June this year increased by 169,000 to 3.0 million. The number of other referrals made has also increased, by 136,000 to 1.7 million – an 8.7% increase against the first quarter of 2009/10.”

Unless this is controlled it will tear apart consortia commissioning. If aspiring GP commissioners have a plan to get a grip on this – meaning their colleagues referral behaviour – now would be a good time to share it with the rest of us (please).

This is all about GP behaviour because they initiate the referrals. It bears out many of the things that we know locally about the poor quality and inappropriateness of many referral letters, but it doesn’t answer the question about why the demand for secondary care is rising at such a rate. No one seems to know and there isn’t one single answer at least in London.

The KF report concludes “A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective.” Which is all well and good, but the snag is there is no incentive either contractual or cultural for referring clinicians to behave like this. Indeed, the built-in motivation is to go on doing what they think is needed for each patient in the name of clinical freedom and underpinned by the present GP contract. The contractual part may have to change soon.

Even if GPs did start exercising a moderating role in referrals (rationing access to secondary care by any other name)it would be time consuming and could increase costs and perhaps even clinical risks if only done to get the numbers down. And yet that is just what GP commissioning consortia will have to do very soon.

Locally our out patient activity shift plans depend on controlling referrals, but the KF report says that even PCT’s operating what they believe are effective demand management systems are not getting the demand control they think they are. They concluded: “Although half the PCTs studied believed that their referral management schemes had managed to curtail demand, the evidence from the quantitative analysis suggests that PCTs with active referral management were, in fact, no more likely to curtail demand than were other PCTs.” That is the really worrying part. We are relying on something for which we have no assurance that it will deliver the goods.