Referral management strategies

This case study follows the 5 step process for accessing and using evidence in response to a request from commissioners to identify strategies for referral management to reduce unnecessary referrals.

Identify

The Clinical Commissioning Group wanted to look at strategies for referral management to reduce unnecessary referrals. They were especially interested to know if a report from the Kings Fund was still relevant – Referral Management: Lessons for Success (2010).

The question that the evidence would help answer was worked out between the commissioner and the evidence reviewer: How effective are referral management strategies at controlling the demand for referrals, and reducing unnecessary referrals?

Using PICO, the scope of the evidence search was defined:

Problem: High number of patient referrals

Intervention: Referral management strategies

Comparator: Usual care

Outcomes: Controlling the demand for referrals (reducing unnecessary)

It was agreed that the evidence review would aim to swiftly identify the post-2010 evidence for the effectiveness of referral management strategies – a ‘good enough’ review to inform decisions.

Access

The commissioners chose not to carry out the search themselves, but had already discussed the topic area with Public Health colleagues who linked them to the Evidence Assistant. This person already had an NHS Athens login.

The search involved the following websites and databases, using the term referral management:

• Cochrane Database of Systematic Reviews (including CENTRAL)
• CRD DARE (including NHS EED and HTA)
• TRIP Database
• NICE Evidence (EMBASE, Medline, BNI, CINAHL, HMIC)
• Google and Google Scholar search engines

It was agreed that the evidence review would aim to swiftly identify the post-2010 evidence for the effectiveness of referral management strategies – a ‘good enough’ review to inform decisions.

Appraise

The Evidence Assistant knew not to accept what they found at face value, so they critically appraised the evidence from the search to identify the higher quality and more reliable pieces.

They summarised each piece of evidence for inclusion into a report, to support a conversation with the commissioners. Evidence from four studies were found to be relevant – ranging from low-moderate quality evaluations to observational studies – and appeared to support the findings of the King’s Fund report.

Apply

The Evidence Assistant met with the commissioner to discuss findings, presented in an easy-to-understand way to help their decision-making.

It was explained that the evidence base had not increased since the publication of the King’s Fund report. Ideally more research was needed to test the effectiveness of referral management strategies. However, in the absence of this, the Evidence Assistant made some recommendations that would strengthen the application of this level of evidence. These included:

• considering the role of GP education to improve referral requests to ensure they are appropriate.
• devising a reliable means of recording outcomes of GP referrals to support better understanding of practice variability, and number of referrals that are appropriate and/or complete.
• Building in evaluation of the individual components was recommended to ensure that they are achieving their stated aims and the findings ad to the evidence base.

Share & manage

The report produced and discussed with commissioners, was saved within a repository so that it could be used by others as necessary.
The report included a summary of findings, a brief overview of the evidence findings and some recommendations. Currently access to the repository is not open, but requires contact to be made with the Evidence Assistant; this allows any caveats relating to its use to be explained before it is used to inform decision making elsewhere.