Pergamon Soc. Sci. Med. Vol. 46, No. 1, pp. 131-136, 1998 © 1998 Published by Elsevier Science Ltd. All rights reserved

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IN-HOUSE REFERRAL: CHANGING GENERAL PRACTITIONERS' ROLES IN THE REFERRAL OF

PATIENTS TO SECONDARY CARE

FRANCES MAGGS-RAPPORT, ~* PAUL KINNERSLEY ~ and PENNY OWEN 2

'Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Maelfa, Llanedeyrn, Cardiff CF3 7PN, UK. and ~Llanedeyrn Health Centre, Maelfa, Llanedeyrn,

Cardiff CF3 7PN, U.K.

Abstract--Innovative approaches to patient management are needed to ensure that only those patients who would benefit most are referred from primary to secondary care. This report describes an explora- tory study in which general practitioners adopted the role of reviewing the management of patients who would otherwise be referred to hospital. Patients in eight general practices in South Wales were referred In-house by general practitioners to a colleague in the practice who reviewed the need for hos- pital care. Qualitative data from interviews and questionnaires is presented. In-house referral appears to be acceptable, practical and of value to both general practitioners and patients. © 1998 Published by Elsevier Science Ltd. All rights reserved

Key words--referrals, changing roles, primary care, U.K. general practice

INTRODUCTION

Traditionally, primary care physicians have made judgements about which patients need to be referred to secondary care in relative isolation. Whilst informal discussions about patients may take place (Newton e t al., 1991; Rowlands, 1997), no attempts have been made to maximise the poten- tial of colleagues working together on the same pre- mises to improve decision making as to whether referral to secondary care is appropriate. This is a report of an exploratory study of In-house referral; that is the referral of patients from one general practitioner to another for a second opinion on their management and, in particular, on the need for secondary care referral.

BACKGROUND

In the British National Health Service (NHS), patients can only gain access to hospital-based, sec- ondary care specialists by referral from their general practitioner. Thus, as in other similar health care systems, the general practitioner acts as the gate- keeper to secondary care. This role is highly valued and considered an important factor in cost contain- ment (Knottnerus, 1991; Starfield, 1994). Increased attention is being placed on the role of general practitioners within the NHS and it was anticipated that the introduction of general practitioner fund- holding would lead to increased patient care within

*Author for correspondence.

primary care and decreased referrals to secondary care (Coulter, 1995).

Each year British general practitioners refer to hospital between 7.9 and 13.2 per 100 patients regis- tered with them (Roland, 1992). New outpatient referrals increased from 5.9 million in 1949 to 9.0 million in 1991, an increase in the referral rate per general practitioner per year of 22% over the four decades (Armstrong and Nicoll, 1995). More recently, larger increases in referrals have been described with no evidence of a decrease as a result of fund-holding (Surender et al. , 1995; NHS Wales Quarterly Statistics, 1996). Within these overall figures, there is a fourfold variation in referral rates between general practitioners (Wilkin, 1992). This has led to concerns as to whether some general practitioners are over-referring patients whilst others are under-referring.

Attempts to explain differences in referral rates in terms of different patient or doctor characteristics have been largely unsuccessful (Morrell et al. , 1971; Cummins et al., 1981; Wilkin and Smith, 1986). While patients are commonly referred for specific treatments, over 60% of referrals are for further in- vestigation, advice on management or reassurance (Coulter et al. , 1989). Morrell e t al. (1971) con- cluded that the decision to refer may reflect the practitioner's perception of the need for hospital care related to his or her level of tolerance of diag- nostic uncertainty. Other explanations include indi- vidual practitioner skills, pressure from patients and the context in which the referral decision is made (Fertig et al. , 1993). In one of the few qualitative

131

132 F. Maggs-Rapport et al.

studies of the referral process, Dowie (1983) suggested that differences in confidence in clinical judgement and differing awareness of the likelihood of life threatening events might explain variations in referral rates. Furthermore, Newton et al. (1991) identified non-clinical factors related to the personal characteristics of the referring doctor as being im- portant. This raises the possibility that those wishing to reduce referral rates or reduce variability should focus attention on the decision making pro- cess rather than on the patients or doctors them- selves.

The impact of a range of interventions on the referral process has been explored. Peer review of referral letters has been undertaken in an attempt to determine the appropriateness and quality of general practitioners' referral decisions (Knottnerus et al., 1990; Jones Elwyn and Stott, 1994). These studies suggest that alternative management could be considered for over one third of patients referred. Coast et al. (1996) explored alternatives to hospital admission for acutely ill patients with panels of general practitioners and found that between 8% and 14% could have been managed in alternative ways. Jones Elwyn et al. (1996) reviewed patients who had already been referred to hospital and found that further management in primary care could be implemented for 9%. However patients once referred were, not surprisingly, keen to see the specialist. Rowlands (1997) described the benefits of regular meetings between clinicians to discuss their referrals in a single practice and found this led to a reduction in referrals. Guidelines for the manage- ment of chronic conditions can lead to improve- ments within primary care (Feder et al. , 1995) but their impact on referral rates is less certain (Fertig et al. , 1993). These studies suggest that innovative approaches could improve decision making about the need for referral. However, to be taken up widely these innovations must fit in readily with daily practice and the needs of both patients and practitioners in primary care.

THE IN-HOUSE REFERRAL STUDY

This is an exploratory study of general prac- titioners reviewing the management of patients for whom their colleagues believe referral is appropriate which has been conducted in South Wales. When participating general practitioners reach the point in care when they would usually refer patients to hos- pital, they instead refer the patients to colleagues who review the need for referral.

In-house referral is attractive since it can provide both practitioner and patient with a second opinion on the problem without unduly delaying hospital referral, should it be necessary. Moreover, since the second consultation is focused on the specific pro- blem, it may be that better care is achieved than in consultations where other clinical conditions may

also be considered. The second general practitioner, by reviewing the patient's overall context (personal, family and social circumstances) and possibly applying special knowledge (as a result of their own personal interests), may be able to provide an alternative and more appropriate management plan and patient preferences may be addressed more thoroughly. If the plan is based solely in primary care, referral to hospital is avoided. Alternatively, the patient may require referral to an agency differ- ent from that originally considered.

Some patients, for whom referral is considered unlikely, may also benefit from an In-house referral, since the second general practitioner may be more aware of potential gains from secondary care. Consequently this may lead to some patients being referred who would not be otherwise. In addition, In-house referral might be anticipated to promote collaborative working between partners within a practice.

However, it should be recognised that along with these benefits there would also be some costs. The additional consultation requires the patient to at- tend the health centre on a second occasion. This can be disadvantageous involving extra time and travel and may prevent them from doing other ac- tivities. For general practitioners, the second consul- tation consumes time and effort which should be taken into consideration and may need to be com- pensated by additional resources.

THE AlMS OF THE STUDY

Newton et al. (1991) has suggested that In-house referrals spontaneously occur occasionally particu- larly in larger practices. However, there are no stu- dies evaluating the process formally. The aim of this study was to change the role of general prac- titioners in the referral process from one in which they worked alone to one in which they collabo- rated over these important decisions. The research- ers were particular interested in the views of general practitioners and patients on the acceptability, prac- ticality and value of this change. In addition, the researchers wished to measure the proportion of patients managed in primary care rather than sec- ondary care after In-house referral and the out- comes of these two alternative patterns of care. These latter findings will be reported elsewhere.

METHOD

A randomised trial of In-house referrals was con- ducted in practices in South Glamorgan and Gwent. Practices were allocated to an intervention or a reference (control) group. In the former, patients requiring referral were referred initially to colleagues within the practice as described. In refer- ence practices, referral to hospital was made by a single general practitioner in the usual fashion. A

Referral of patients to secondary care 133

reference group was judged necessary to make quantitative comparisons for the outcomes of In- house referrals, there being no readily available comparative data on outcomes for patients being referred. (These findings will be reported sub- sequently).

All practices with three or more partners in East Cardiff and Gwent were arranged in random order. They were then approached sequentially until the target of 16 participating practices was reached. Details of the study were sent to the senior partner in each practice and, if agreeable, a meeting was arranged between the partners and the research team. Practices agreeing to participate in the study were then randomised to either intervention or reference groups.

The intention was to recruit 30 patients in each practice. The research was restricted to patients aged 18 and over requiring non-urgent referral to Dermatology, ENT, Ophthalmology, Gynaecology, Orthopaedics and Rheumatology outpatient clinics. The study was restricted to these conditions to avoid over-burdening practices with additional con- sultations. These particular specialities were chosen because they are high referral areas, making up around 25% of all hospital referrals (Wilkin, 1992). It was emphasised that the second consultation should be a distinct episode of care rather than con- firmation by the second practitioner of the initial management plan during the first consultation.

During the study period, eligible patients were informed of the study by their general practitioners. Patients consenting to undergo In-house referrals were asked to make an appointment with the sec- ond doctor at their convenience. The referring gen- eral practitioner used the clinical records to detail their findings, commenting on the need for a second opinion. The extent to which conferring took place between partners, either before or after the second consultation, was decided by the practitioners involved.

All the practitioners in the intervention practices were interviewed at the end of the study period. Informal interviews were conducted with each group of practitioners by a study clinician (PK) and a non-clinical researcher experienced in qualitative research (FMR). Each interview lasted between 20- 40 minutes. The research team decided to take detailed notes instead of recording the interviews, believing that this would set participants more at ease. As many verbatim quotations were recorded as possible and these were checked back with the subjects at the end of the interviews. It was felt that group interviews within practices would enable par- ticipants to express both positive and negative views, whilst researchers observed the interactive process (Morgan, 1988). In addition, participants were asked to comment in writing on their experi- ence of the study. They concentrated at first on gen- eral themes coming through from the data and after

initial analysis looked more closely for specific data categories. Once these were identified a coding sche- dule was developed. Categories were validated and refined through second-party analysis with the help of the third member of the research team who had not been involved with data collection (PO) (Hammersley, 1992).

Patients' views of In-house referral were sought by postal questionnaire. These were sent shortly after their second consultation. Patients were asked to report on their experience of seeing a second gen- eral practitioner. The questionnaire also contained instruments to measure patient satisfaction and health status for the quantitative arm of the study. Non-respondents were followed up with a single reminder. The qualitative views of patients in the reference practices were not sought.

RESULTS

During recruitment, 50 practices were informed of the study, 27 met the research team and 16 agreed to participate. However, one practice allo- cated to the reference group withdrew immediately after starting the study. Whilst most of the practices who declined to participate cited the additional work involved, one group of practitioners expressed strong views that they felt the intentions of the study were misguided. In particular, they were con- cerned that the requirement for a second consul- tation implied some criticism of the initial referral decision.

Forty-one (67%) of the practitioners who agreed to take part in the study were male and 20 (33%) were female. Fifty-four (89%) were full-time and five (8%) part-time and they had been qualified as doctors for an average of 16 years (range 6-31 years). Thirty-two (52%) were members of the Royal College of General Practitioners, 25 (41%) possessed the Diploma of the Royal College of Obstetricians and Gynaecologists and two (3%) were members of the Royal College of Physicians. The study general practitioners were similar in gen- der, number of years qualified and membership of the Royal College of General Practitioners to other samples recruited into research studies in South Wales (Paul Kinnersley--unpublished MD data).

In total, 327 patients (177 from intervention prac- tices and 150 from reference practices) were recruited into the study in the time available. There were no notable differences in terms of age and gen- der between those patients recruited in the interven- tion practices and those in the reference practices.

PRACTITIONERS' VIEWS ON THE IN-HOUSE REFERRAL PROCESS

During interviews with the eight groups of prac- titioners who carried out In-house referrals, there was general agreement that they were acceptable,

134 F. Maggs-Rapport e t al.

practical and of considerable value for some patients. There was consensus of opinion that In- house referral provided a useful management option and was applicable to all groups of patients, not just the clinical specialities chosen for the study. Further discussions identified three broad areas of importance: the changing role of the general prac- titioner, the way in which colleagues within prac- tices worked together and anecdotal comments. Each of these areas will be considered separately.

THE CHANGING ROLE OF THE GENERAL PRACTITIONER

Although general practitioners were used to seek- ing advice from colleagues in an informal manner, formalising the process had a marked effect. Doctors reported that they were comfortable review- ing each others' management plans and found this to be of interest. There appeared to be particular benefits for patients who had been consulting repeatedly about the same problem. In these circum- stances, the second clinician was more likely to suggest a change in patient management when the first general practitioner had run out of ideas. The doctors commented that this fresh outlook on the patient's problem was useful and led to changes in medication and investigations. It was also recog- nised that In-house referral could be used to antici- pate problems. Furthermore, it enabled practitioners to take more control over patient management ask- ing the patients whether they wanted to see someone else within the practice instead of waiting for the patient to go to hospital or to another general prac- titioner of their own accord. One practice were so enthusiastic that they reported that they were going to institute In-house referral for all patients con- sidered to need hospital care.

There were no expressions of concern that In- house referral could be a threatening process. On the contrary, it had the effect of harnessing the gen- eral practitioner's knowledge and served as a stimu- lus for formalising patient management review which could be a useful way to increase skills required by the general practitioner. It was recog- nised that there could be drawbacks to increasing specialist skills. If one of the partners became seen as the practice expert, other colleagues might feel de-skilled.

cussed within the practice. This was welcomed as it appeared to be an activity carried out infrequently. One doctor commented "we used to do this when I first entered practice (10 years ago) but we just don't get time for it now". Discussions occurred most regularly when decisions were not cut-and- dried and when the diagnosis fell within a grey area, that is where the diagnosis was unclear.

General practitioners were open when it came to discussing personal strengths and weaknesses. Some doctors reported that they were higher than average referrers and acknowledged that such behaviour could be reassessed. One doctor commented on see- ing fewer acute medical cases than her partners, and as a result lacked confidence to take these sorts of cases on board. However this same doctor reflected "this study has made me try to evaluate my referrals more rationally". Another practitioner commented "as a result of the exercise I have now changed my practice and think that in future I might make more use of my colleagues".

Some practitioners expressed considerable enthu- siasm for a regular review of their referral decisions and one commented "I 'd love to have someone look at all my notes for we all ought to have an input. It may even be a good idea to scan notes between practices".

ANECDOTAL COMMENTS

The project led to a reassessment by general prac- titioners of their referral behaviour. One commen- ted "we all refer too heavily", whilst another argued "few patients who are referred to hospital care cannot be dealt with in the practice". There was some concern that, at present, practitioners were missing out on follow-up of patients due to lack of feedback from the consultants. One doctor commented "you don't learn very much from con- sultants' letters about some treatments and investi- gations", with another feeling the way to take control was to "build up practices where prac- titioners have stated areas of specialist skill". With this kind of expertise, they argued, practitioners could command follow-up care with greater aware- ness and confidence.

PATIENTS' VIEWS ON THE IN-HOUSE REFERRAL PROCESS

COLLABORATIVE WORKING PRACTICE

Prior to the intervention, it appeared that the general practitioners only discussed the manage- ment of patients infrequently and that there was lit- tle evidence of collaborative working regarding referral decisions. Although the practitioners did not discuss every patient who had been referred In- house, the doctors reported a marked increase in the extent to which patient management was dis-

Of the 177 patients who underwent an In-house referral, 130 (73%) returned the questionnaires sent to them. Of the 83 responding patients referred to hospital after their second consultation, 42 (51%) responded positively, six (7%) responded negatively and 35 (42%) did not comment. Of the 47 patients not referred to hospital as a result of their referral In-house, 14 (30%) responded positively, nine (19%) responded negatively and 24 (51%) did not comment.

Referral of patients to secondary care 135

The most commonly used positive adjectives were reassuring, "helpful" and "useful". Twenty-seven of the patients referred to hospital made comments which fell within these three categories. In addition, another five patients expressed relief that their doctor was concerned enough about their problem to send them to see a second doctor. One of these patients commented "it is encouraging that the first doctor is concerned enough to seek another opinion without just expecting the patient to accept his in- itial diagnosis".

Those patients who underwent an In-house refer- ral and were referred to hospital were more enthu- siastic than those not referred to hospital, and yet in both groups the majority of comments were posi- tive. Patients described the process as "very encouraging and pleasant". One patient said "it left me feeling that O.K., I am not imagining my pro- blem as two doctors agree that it should be looked into", and another patient said "it gave me time between the two visits to think of the sorts of ques- tions which arose from the first visit that I could ask the second doctor".

The most commonly used negative adjective with which patients described their experience of an In- house referral in the questionnaire was "apprehen- sive". For example, one patient commented "I know in my mind that it is good to see another doctor, but it did wind me up, made me apprehen- sive". Another said "I was apprehensive thinking the condition was serious. The problem was con- firmed and a further stated that all visits have pro- ven to be fruitless. I am apprehensive as I still have the same problem".

None of the patients described difficulties in attending for a second consultation. Nor did any of the patients feel that it was a waste of time seeing a second practitioner in the first instance if they were eventually referred to hospital. Furthermore, patients did not express concern about being diag- nosed by a general practitioner as opposed to a hospital specialist. However, problems arose where concerns were not addressed during the consul- tation and when fears were not allayed by the sec- ond doctor.

Patients' comments supported the new role of the general practitioner. Respondents described their re- lationship with their doctor as "ongoing and close". One patient described the second practitioner as "more helpful than any other doctor that I have seen in the previous two years for the same pro- blem".

DISCUSSION

For any innovation intended to change daily clinical practice, it is very important that the views of both patients and practitioners are sought. This is of particular importance for an innovation which may reduce referrals to hospital and for which the

economic imperative may be such that the overall consequences are not considered fully. This explora- tory study indicates that both general practitioners and patients judge In-house referrals to be largely acceptable, practical and of value. Indeed, the parti- cipating doctors expressed considerable enthusiasm for the change introduced. The role of reviewing a colleague's patient management was readily adopted by the general practitioners. In-house referral pro- vided new management options. Furthermore, prior to their introduction, doctors rarely discussed their referrals and they appreciated greater collaborative working. This confirms the finding that general practitioner satisfaction is increased if they can con- tinue the management of their own patients (Harlow and Burton, 1996).

In any study which uses busy clinicians to recruit patients it is likely that there will be some loss of recruitment. In this study it is possible that some patients who should have been recruited into the study were not and, in intervention practices, were referred directly to hospital. Also it is possible that some patients who would not have been referred to hospital had the study not been conducted were referred In-house. The study may have influenced the recruitment and referral rates in the reference practices. Nevertheless, in the time allowed 177 patients were referred In-house and nearly three quarters returned questionnaires reporting on their experiences. Further research is needed but the results indicate considerable support amongst the general practitioners and patients for this inno- vation.

It is notable that a second opinion is valued by patients even when their management does not change. Having had a second consultation within the practice, the patients report positively that they feel their problem was taken seriously and dealt with in a thorough and systematic fashion. With long hospital waiting lists and problems of access to service provision, In-house referrals may offer patients both a rapid and effective service. These results support the findings of Armstrong and Grace (1987) that over 50% of patients referred to hospital believe that their doctor could have done more for them.

The intention of this study was that the second general practitioner should provide a second gener- alist opinion. However, the results could be inter- preted as supporting general practitioners developing special skills. This would enable them to act as the practice In-house referral specialist for particular conditions. Whilst there may be some benefits in the development of areas of clinical expertise, the value of a second generalist opinion should be fully appreciated. As a generalist, the sec- ond doctor may be more likely to consider contex- tual events occurring in the patients life at the time, rather than being drawn into specialist investi- gations (Franks et al. , 1992). If the second doctor

136 F. Maggs-Rapport et al.

acts as a sub-specialist, there may be few advan- tages of In-house referral apart from the second opinion being provided rapidly and conveniently close to the patient's home. Furthermore, it appears from the practitioners' comments that such intra- practice specialisation may lead to other doctors within the practice feeling less secure in their abilities.

Clearly it is unlikely that In-house referral is necessary for every patient for whom a general practitioner is considering referral. However, used with care it can provide a valuable opportunity for a review of patient management and could lead to more appropriate referral decisions. It has the po- tential to address both under-referral and over- referral of patients. If taken up widely, there would need to be a shift of resources from secondary to primary care in recognition of the transfer of work- load. In these circumstances, further research is needed to demonstrate that the additional workload for In-house referrals is not excessive in comparison with any reduction in referrals to hospital achieved.

At present general practitioners appear to be working in greater isolation from their colleagues than might be anticipated. This research shows that In-house referral facilitates collaborative working about referral decision making. As with any inno- vation, In-house referral will be taken up with vary- ing enthusiasm by clinicians but it appears attractive to both general practitioners and patients. Further research is needed to fully assess the ben- efits but this study suggests that In-house referral should be undertaken more widely.

Acknowledgements--This research is funded by a grant from the National R & D Programme in the area of the primary-secondary care interface (North Thames NHS Executive). We would also like to thank the general prac- titioners and patients who took part in the study.

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