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Presents the results of a study which investigated whether the quality of information provided by GP referral letters to a community mental health team (CMHT) was sufficient to determine an appropriate response and the allocation of professional resources. A random sample of GP referral letters received over a six‐month period was analysed. The presenting problem, diagnosis and the indication of severity of symptoms were rated. Perusal of the CMHT members’ replies to the GPs allowed a rough analysis of the extent of agreement with the GPs’ diagnoses, description of presenting problems and severity of symptoms. Discusses the results of the study with regard to the implications of GP fundholding and the employment of GP‐based counsellors.

One of the major goals of the recent NHS reforms has been to make the NHS more responsive to the needs of patients by offering more choice. DHAs and budget‐holding GP practices have been given an incentive to obtain better value for money in purchasing health care services. In doing so they will have to take account of the existing GP referral patterns for as “key advisers” GPs can have major influence on patients′ choice of hospitals and consultants. Until now not much has been known about the structure, development and change of referral patterns and the factors responsible for changes. A study concerning these issues, conducted in The Netherlands, provides relevant information for the British situation. The results (non‐specificity of referrals, the role of tradition and distance in building up referred relationships and patients′ influence on breaking up relationships) suggest that GPs′ decisions in building up and changing referral networks take place implicitly. Concludes that GPs need more information in order to choose the best option. Information exchange within GP practices or local/regional GP groups is a means of improving the basis for decision making. At the same time there is a growing need for research into cost/quality ratios of care offered by health care providers. In Britain, DHAs could play an important role in initiating and intensifying this research.

In order to decrease patient waiting time and improve efficiency, healthcare systems in some countries have recently begun to shift away from decentralized systems of patient referral from general practitioners (GPs) to specialists toward centralized ones. From a queueing theory perspective, centralized referral systems can decrease waiting time by reducing the variation in the referral process. However, from a social psychological perspective, a close relationship between referring physician and specialist, which is characteristic of decentralized referral systems, may safeguard against high referral rates; since GPs refer patients directly to the specialists whom they know, they may be reluctant to damage that relationship with an inappropriate referral. The purpose of this paper is to examine the effect upon referral behavior of a relationship between physicians, as is found in a decentralized referral system, vs a centralized referral system, which is characterized by an anonymous GP-specialist relationship. In a controlled experiment where family practice residents made decisions concerning referral to specialists, physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by the design of the service system and will, in turn, affect system performance.

The authors used a controlled experiment to test the research hypotheses.

Physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by system attributes and will, in turn, affect system performance.

The current study has some limitations, however. First, the sample consisted only of family practice residents and did not have the knowledge and experience of GPs regarding the referral process. Second, the authors used hypothetical patient case descriptions instead of real-world patients. Repeating this experiment with primary care physicians in real setting would be beneficial.

The study indicates that decentralized referral systems may act (rightly or wrongly) as a restraint on the rate of referrals to specialists. Thus, an implementation of a centralized referral system should be expected to produce an increase in referrals simply due to the change in the operational system setup. Even if centralized referral systems are more efficient and can facilitate the referral process by creating a central queue rather than multiple single queues for patients, the removal of social ties such as long-term social relationships that are developed between GPs and specialists in decentralized referral systems may act to counterbalance these theoretical gains.

This study provide support for the idea that non-clinical factors play an important role in referrals to specialists and hence in the quality of provided care, as was suggested by previous studies in this area (Hajjaj et al., 2010; Reid et al., 1999). The design of the service system may inadvertently influence some doctors to refer too many patients to specialists when there is no need for a specialist visit. In high-utilization health systems, this may cause some patients to be delayed (or even denied) in obtaining specialist access. Healthcare systems may be able to implement behavioral-based techniques in order to mitigate the negative consequences of a shift to centralized referral systems. One approach would be to try to create a feeling of close relationship among doctors in centralized referral systems. High communication and frequent interaction among GPs and specialists can boost the feelings of teamwork and personal efficacy through social comparison (Schunk, 1989, 1991) and vicarious learning (Zimmerman, 2000), which can in turn motivate GPs to take control of the patient care process when appropriate, instead of referring patients to specialists.

The authors’ study is the first examining the effect of social relationships between GPs and specialists on the referral patterns. Considering the significant implications of referral decisions on patients, doctors, and the healthcare systems, the study can shed light into a better understanding of the social and behavioral aspects of the referral process.

The dermatology service on the islands of Orkney, with a population of approximately 22,500, was taken over by National Health Service (NHS) Tayside in August 2018. This paper aims to provide an overview of the planning and review of a highly efficient and effective dermatology service for a rural island population.

The service includes visiting dermatology consultants, enhanced electronic referral vetting, skin surgery services, a General Practice (GP) with extended role (GPwER) in dermatology, specialist virtual clinics, urgent advice for inpatients at the local district general hospital and remote systemic therapy monitoring. A new phototherapy service has been set up in an island GP practice.

Local GPs and consultant dermatologists find the enhanced vetting service useable, efficient and educational. Between August 2018 and November 2022, there have been 1,749 referrals. Of these referrals, 60% were seen in clinic or a GPwER surgery, with 40% managed remotely by providing advice back to the referring GP. The number of consultations performed by the GPwER has grown over the past 3 years, and in the last year, it accounted for more than 50% of patient appointments. The waiting time has been significantly reduced using this model.

This remote service uses an integrated approach of teledermatology (TD) whilst offering continual in-person services using local capabilities including a GPwER and island general surgeons. New treatment facilities are provided to the island population. Continual educational feedback to the primary care referrer is provided, and it enhances relationships that greatly aid the high-quality dermatology service provided.

The purpose of this article to study referrals to our hand service to find out how long they had been waiting and with what sort of clinical conditions. The Department of Health monitors outpatient's waiting time as the percentage of patients seen within a 13‐week target. This target does not include patients referred by consultants or other health professionals.

All the referral letters from other consultants or healthcare professionals still awaiting appointments were collected. The referrals were read and studied to ascertain the most likely diagnosis. This was recorded along with the source of the referral and the details to whom the referral was made. The date of the referral letter being received by the department (date stamped) was also noted.

A total of 157 referrals from consultants or healthcare professionals were waiting outpatient dates. The median waiting time was 448 days (range 20‐952 days). The most frequent source of referrals was from the orthopaedic department. Carpal tunnel syndrome was the most common problem awaiting an outpatient appointment.

The wait for a clinic appointment for these patients is long. This has come about as the result of the fact that the government targets for outpatient waiting times have been set for GP referrals alone and exclude referrals that have been made by other consultants or other healthcare professionals. This is a clinical governance issue for the Hospital Trust, the Primary Care Trust and for general practitioners.

Higher caseloads are associated with better outcomes for many conditions treated in secondary and tertiary care settings, including colorectal cancer (CRC). There is little known whether such volume-outcome relationship exist in primary care settings. The purpose of this paper is to examine general practitioner (GP) CRC-specific caseload for possible associations with referral pathways, disease stage and CRC patients’ overall survival.

The paper retrospectively analyses a prospectively maintained CRC database for 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services.

Of 1,145 CRC patients, 937 (81.8 per cent) were diagnosed as symptomatic cancers. In total, 210 GPs from 44 practices were stratified according to their CRC caseload over the study period into low volume (LV, 1-4); medium volume (MV, 5-7); and high volume (HV, 8-21 cases). Emergency presentation (LV: 49/287 (17.1 per cent); MV: 75/264 (28.4 per cent); HV: 105/386 (27.2 per cent); p=0.007) and advanced disease at presentation (LV: 84/287 (29.3 per cent); MV: 94/264 (35.6 per cent); HV: 144/386 (37.3 per cent); p=0.034) was more common amongst HV GPs. Three-year mortality risk was significantly higher for HV GPs (MV: (hazard ratio) HR 1.185 (confidence interval=0.897-1.566), p=0.231, and HV: HR 1.366 (CI=1.061-1.759), p=0.016), but adjustment for emergency presentation and advanced disease largely accounted for this difference. There was some evidence that HV GPs used elective cancer pathways less frequently (LV: 166/287 (57.8 per cent); MV: 130/264 (49.2 per cent); HV: 182/386 (47.2 per cent); p=0.007) and more selectively (CRC/referrals: LV: 166/2,743 (6.1 per cent); MV: 130/2,321 (5.6 per cent); HV: 182/2,508 (7.3 per cent); p=0.048).

Higher GP CRC caseload in primary care may be associated with advanced disease and poorer survival; more work is required to determine the reasons and to develop targeted intervention at local level to improve elective referral rates.

The patient journey from detection of an eye problem by optometrists to assessment and treatment by ophthalmologists can be streamlined by direct referral from optometrist to hospital eye service (HES). This requires locally agreed guidelines and training and feedback for optometrists to ensure high diagnostic competence. The purpose of this paper is to evaluate the quality of the West Suffolk Direct Referral Scheme, one of the first direct referral schemes in the UK to include all ophthalmic sub‐specialties.

Two‐cycle audit of existing practice, including all new patients referred by optometrists and seen at West Suffolk Hospital during a three‐month period in 2003 and a seven‐week period in 2006. Three interventions: direct referral clinics for urgent patients; introduced in 2003; six‐monthly training sessions for optometrists; and regular, prompt feedback via letter about individual consultation outcome. Prospective data collection via proforma in both cycles; additional retrospective data collection in the second cycle. Diagnostic accuracy, perception of urgency and request of subspecialty clinic were evaluated.

The direct referral scheme streamlines the patient journey, and patients with acute problems have fast access to HES. In total, 99 per cent of referrals are appropriate. Diagnostic competence is high (87 per cent), and has improved with tighter communication between HES and optometrists. Agreement is less for referral urgency (75 per cent) and choice of subspecialty clinic (74 per cent).

The West Suffolk Direct Referral Scheme provides an efficient service of high quality. Good communications and continued feedback between community‐ and hospital‐based eye care services improve standards and facilitate efficient use of resources.

Fundholding (the opportunity to hold a budget at practice level) has given general practitioners (GPs) purchasing power for medical services within the reformed UK National Health Service (NHS). This new purchasing power equates to financial leverage with the NHS consultants in hospitals. Argues that fundholding is presented as an opportunity for GPs to engage in a “turf battle” with the hospital consultants without this battle becoming publicly visible. Fundholding as an accounting‐based intervention masked the nature of the professional challenge which GPs launched against the consultants and, hence, allowed territorial claims to be renegotiated through the medium of contracting. This circumvented the damage to medical professional ideologies which would have ensued if intra‐professional conflicts had become overt. The empirical study which is referred to indicates that GPs are using contracts to improve processes of case management at the hospital interface (an area where consultants have failed to communicate with GPs) and to have an input into the setting of quality standards within the hospitals. The increased financial flexibility conferred through holding budgets is also enabling GPs to expand in‐house services for primary care. Theorizes the changing power relations between GPs and consultants through exploring four dimensions of intra‐professional differentiation: task specialization; client differentiation; organization of work; and career pattern. Concludes that budgets have constituted a catalyst for professional development through reconnecting the monetary bonds between the polarized professionals in British medicine. This study indicates that, as fundholding progresses, the boundary between primary and secondary care is becoming blurred; that lead fundholding GPs are being managerialized; and that the purchasing dialogue between the GPs and the Trusts is marginalizing the role of the Health Boards (bodies which had previously held sole responsibility for the co‐ordination and delivery of health care but which now have a more limited purchasing/commissioning role).

The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.

With the increasing demand on ambulance services, paramedics are tasked to arrange as much out of hospital care as possible, to develop integrated systems of care and work with hundreds of different providers – all in the 15 minutes allocated for assessment. A UK ambulance trust is navigating and leading much of this work as one of the first trusts to implement a general practitioner referral policy as an alternate to direct conveyance. The paper aims to discuss this issue.

Here the authors discuss the referral scheme, examine the limited evidence available and discuss what is needed to influence prospective success of implementing this scheme in other trusts.

Limited evidence for these schemes are described, however there is a clear gap in critical appraisal and methodologically rigorous evidence needed to implement these schemes in other ambulance schemes.

In order to facilitate collaboration of healthcare services and to minimize the burden of increasing numbers of patients, communication and discussion of alternate routes of care is crucial. This viewpoint piece is one of the first to emphasize the potential benefits of such schemes.