Reducing variation in general practitioner referral rates through clinical engagement and peer review of referrals: a service improvement project

Qual Prim Care. 2011;19(4):263-72.


Background: General practitioner (GP) referral rates to hospital services vary widely, without clearly identified explanatory factors, introducing important quality and patient safety issues. Referrals are rising everywhere year on year; some of these may be more appropriately redirected to lower technology services.

Aim: To use peer review with consultant engagement to influence GPs to improve the quality and effectiveness of their referrals.

Design: Service development project.

Setting: Ten out of 13 GP practices in Torfaen, Gwent; consultants from seven specialties in Gwent Healthcare NHS Trust; project designed and managed within Torfaen Local Health Board between 2008 and 2009.

Methods: GPs discussed the appropriateness of referrals in selected specialties, including referral information and compatibility with local guidelines, usually on a weekly basis and were provided with regular feedback of 'benchmarked' referral rates. Six-weekly 'cluster groups', involving GPs, hospital specialists and community health practitioners discussed referral pathways and appropriate management in community based services.

Results: Overall there was a reduction in variation in individual GP referral rates (from 2.6-7.7 to 3.0-6.5 per 1000 patients per quarter) and a related reduction in overall referral rate (from 5.5 to 4.3 per 1000 patients per quarter). Both reductions appeared sustainable whilst the intervention continued, and referral rates rose in keeping with local trends once the intervention finished.

Conclusion: This intervention appeared acceptable to GPs because of its emphasis on reviewing appropriateness and quality of referrals and was effective and sustainable while the investment in resources continued. Consultant involvement in discussions appeared important. The intervention's cost-effectiveness requires evaluation for consideration of future referral management strategies.

MeSH terms

  • Benchmarking
  • Female
  • General Practice / organization & administration*
  • General Practice / statistics & numerical data
  • Guideline Adherence
  • Humans
  • Male
  • Medicine / organization & administration
  • Medicine / statistics & numerical data
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians' / organization & administration*
  • Practice Patterns, Physicians' / statistics & numerical data
  • Quality Improvement / organization & administration*
  • Quality Improvement / statistics & numerical data
  • Referral and Consultation / organization & administration*
  • Referral and Consultation / statistics & numerical data
  • State Medicine / organization & administration
  • State Medicine / statistics & numerical data
  • United Kingdom