What happens to your referral

Seventh in the How GPs are paid series.

In theory, a GP referral is the simplest thing in medicine. I decide you need a specialist, I write a letter — historically, quite literally on the back of anything to hand — and off it goes. Even fifteen years ago GPs were making more than nine million referrals a year, triggering many billions of pounds of expenditure, which is why that envelope has acquired so much machinery around it. Some of the machinery helps. Some of it, the evidence says, mostly costs money. Telling them apart matters.

Triage done well

Medicine has fragmented into more specialties and sub-specialties than any generalist can hold in their head. I might reasonably refer a breathless patient to general cardiology; a good triage service knows the heart failure clinic two corridors along will see them quicker and better. That kind of single point of access — a clinician actively steering referrals to the right service — is the defensible version, and there’s decent evidence behind the model. When Stoke-on-Trent put experienced MSK clinicians in front of GP referrals, only 7% went on to orthopaedic surgeons; 39% went back to GP care with a plan. NHS England’s own guidance notes almost a third of orthopaedic outpatients used to be discharged after a single attendance — consultant time spent confirming an operation wasn’t needed.

Advice & Guidance is the newest version: ask the specialist before referring. The honest scorecard, per the Nuffield Trust: 2.2 million requests in eight months, about half resulting in the patient not joining a waiting list — and yet referrals overall still rose 3%, and the £20 fee for the GP work involved has already been rolled into the global sum. It helps patients get answers faster. Whether it shrinks anything is less clear.

Triage done to you

Then there’s the other kind: the referral management centre, where referrals are checked — sometimes by a private company, sometimes at £10 a letter — and a proportion come back. Here the evidence is unusually one-way. The King’s Fund concluded fifteen years ago that full-scale referral management centres are “unlikely to present value for money” and carry clinical risk at the handover. A Norfolk evaluation found referral management reduced outpatient attendances in no group studied — one centre was associated with more attendances — while costing five times as much per patient as GP peer review, which worked just as well. An NIHR study found even the people running the centres couldn’t demonstrate savings. A GPonline FOI investigation found costs of £2–£60 per referral assessed, one CCG bouncing 35% of referrals in its early months, and a third of areas with centres admitting to processing errors — lost letters, delayed care, one breach of confidentiality. The RCGP’s verdict in 2018 was blunt: “GPs need referral support, not referral management” — and the good-quality evidence that the centres are cost-effective “does not exist”.

From the practice end, a bounced referral doesn’t disappear. It comes back as work: a request for tests before re-referral — often with no contractual basis, as the BMA points out — an anxious patient to see again, a second letter to write. The referral was a cost to be managed; the workload it generates lands somewhere no one is counting.

And there’s a newer cousin: waiting-list validation, where patients waiting a long time are contacted to check they still need to be seen. Entirely sensible as data hygiene — lists do contain people who’ve moved, recovered or gone private. But the incentives deserve daylight: hospitals are now paid per patient removed — £33 a time, with over 250,000 removals in a single month — and the Nuffield Trust’s dry observation was that some of the fall in the waiting list is “tidying up the data”. NHS England rejects the implication. I’ll note only that when a system is measured on the length of a list, every mechanism that shortens the list without treating anyone will always find friends.

Nobody defined the boundary

Underneath all of this is a fact that surprises people: there is no list, anywhere, of what work belongs in general practice and what belongs in hospital. The GMS contract defines essential services in one gloriously circular sentence — the management of patients who are ill or believe themselves to be ill, delivered in the manner determined by the practice. That’s it. The boundary is set by custom, argument and, increasingly, interface rules bolted onto the hospital contract: hospitals shouldn’t make GPs re-refer patients who missed an appointment, should make their own onward referrals, issue their own fit notes and supply their own post-discharge medication. Those rules exist because the work was drifting one way. NHS England’s recovery plan reckons practices spend 10–20% of their time on this interface churn.

The asymmetry nobody planned

Here’s the structural oddity, and I’ll state it carefully because I don’t think anyone designed it. The evidence above suggests the cheap, effective interventions are at the front end: peer review among GPs, specialist advice, a good triage clinician, perhaps a GP with a special interest running a community clinic. Yet commissioners have historically found it hard to invest there — partly, I suspect, because money given to general practice visibly becomes partner profit, which reads badly in a way that money absorbed by a hospital deficit somehow doesn’t; and partly because for a decade GPs themselves led the commissioning bodies, so paying member practices meant conflict-of-interest hoops that paying a hospital never did. Both are real; neither changes where the evidence says the money works. Meanwhile the same system pays profit-making private hospitals to do 9–10% of all NHS elective care — nearly one in five admitted elective patients, a sector the NHS was already paying £9.7 billion a year before the post-Covid recovery deals. Profit is apparently acceptable in the system — just not in the surgery.

Lord Darzi’s investigation put the wider drift in one sentence: between 2006 and 2022 the hospital share of the NHS budget rose from 47% to 58%, while “successive governments have promised to shift care away from hospitals and into the community. In practice, the reverse has happened.” Not my words — the government’s own reviewer.

The fix isn’t mysterious, and the evidence has pointed the same way since 2010: support referrals at the source — peer review, specialist advice, clinically-led triage into the right clinic — rather than inspecting them afterwards. It’s cheaper, it’s safer, and it treats the nine million envelopes as clinical decisions to be improved rather than paperwork to be policed.

If this article was useful, the workshop version is better. Howbeck Healthcare — where I’m a director — runs sessions on how general practice and the primary care marketplace work: one to three hours online with your team, or a half or full day in person, bespoke to your organisation, with guest speakers from our network of senior NHS leaders where needed. Practices, PCNs, pharma, IT and service companies all welcome. Details and contact.

Sources: King’s Fund — Referral management: lessons for success (2010); BJGP — Norfolk referral management evaluation; NIHR — referral management substudy; Healthcare Leader — RCGP on referral management centres; GPonline — FOI on referral scrutiny; BJGP — Stoke MSK CATS; NHS England — MSK referral optimisation; Nuffield Trust — Advice & Guidance analysis; LBC — waiting list removals; GMS Contracts Regulations 2015, reg 17; BMA — external un-resourced workload; BMA — primary and secondary care working together; NHS England — delivery plan for recovering access; IHPN — quarterly NHS data; King’s Fund — is the NHS being privatised?; Darzi investigation — summary letter. England only.