What works in managing referrals from primary to secondary care?


This study, from a team at ScHARR, University of Sheffield, is one of the latest reports from the NIHR Health Services and Delivery programme. The study aimed to assess the factors impacting the effectiveness of referral management interventions. Given the current focus on how to manage increasing demand, the study is timely and could be used by commissioners to inform the design of local service transformation and change programmes.


The study is a novel combination of systematic review with logic modelling synthesis techniques. The authors have published a separate paper detailing their methodology. The study focuses on:

  • Population:  primary care physicians, secondary care specialists and their patients;
  • Intervention: any interventions designed to manage or improve referrals between primary and secondary care, categorised as education, process change, system change and patient-focused interventions;
  • Comparisons: standard practice;
  • Outcomes: all related outcomes including referral rates, referral quality, appropriateness, conversion rates, impact, costs, health outcomes, length of stay as well as patient-oriented outcomes such as satisfaction.

A comprehensive and iterative search strategy (a list of sources searched as well as the strategy used is included in appendices) incorporated database searches, reference list checking, grey literature and citation searching. A total of 290 studies were reviewed, including studies of interventions as well as opinion pieces and case studies.

One problem facing the team is that many implementations haven’t been formally evaluated or published, leading to gaps in the knowledge base and limiting the opportunity to learn from what may or may not work in different contexts.

The study set out to address the following questions:

  • What can be learned from the international evidence on interventions to manage referral from primary to specialist care?
  • How can international evidence on interventions to manage referral from primary to specialist care be applied in a UK context?
  • What factors affect the applicability of international evidence in the UK?
  • What are the pathways from interventions to improved outcomes?

The research team also conducted a consultation exercise – via presentations, meetings and experts (practitioners, commissioners and academics) – and a review of other reviews in this area, to sense check their findings.

secondary care clinicians

The study explored interventions to improve and manage referrals to secondary care.


The research team grouped interventions into 4 categories:  education; process change; system change; and patient-oriented interventions. The evidence seems to be stronger for peer review and feedback; improved referral information; specialist advice prior to referral; electronic referral; and provision of community-based specialist services.

However, the authors suggest that a combination of interventions considered at a system level will be more effective at improving the quality of referrals than a focus on a single intervention. For many interventions, the evidence base is limited or conflicting, making it difficult to draw firm conclusions.

The review shows a wide variation in the outcome measures used to assess the quality of referrals and very few studies reporting on change management. The authors recommend a system-level view to better understand interdependencies (such as waiting times and access to specialists) and the impact and influence of knowledge, attitudes and behaviours. Interestingly, the research team found limited and inconsistent evidence on gatekeeping and referral management services.

The logic model (on page 93) is a presentation of the pathway between interventions and planned outcomes, which handily indicates the strength and nature of the evidence base.  As with any research, there are some limitations (the logic model can only present on findings from the literature so it cannot present on interventions for which there is no evidence).

The review offers a timely insight into a topic which is highly relevant for commissioners, particularly with regards to service transformation, and should be invaluable to commissioners exploring demand management and/or utilisation review.


The report suggests a system level approach to demand management is more effective.


The review highlights a number of areas where the evidence base is under-developed or inconsistent, pointing to gaps in knowledge. As the saying goes, absence of evidence isn’t necessarily evidence of absence. Decisions still need to be made and can’t wait until there is sound and consistent evidence – but commissioners will need to understand where the knowledge gaps exist and develop plans to conduct robust evaluation to help address those gaps.

The authors acknowledge the complexity of demand management – for example, it can be hard to gauge if an outcome is entirely positive, such as an increase or decrease in referral rates. In particular, the concept of “appropriateness” is especially challenging.

Commissioners are ideally placed to facilitate conversations involving primary and secondary care to develop system-wide approaches to demand management. Questions to consider might include:

  • Where are the most significant variations and potential outliers for referrals?
  • How does the current demand management strategy compare with the evidence base?
  • What measures are currently monitored to evaluate the quality of referrals?
  • What influencing factors (e.g. waiting times, access to specialists, GP workload) are specific to your local context?
  • How do the local interventions and strategies address culture change?
peer review

Peer review and feedback were found to be helpful in improving the quality of referrals.


Blank, L et al (2015) What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis, Health Services and Delivery Research, 3 (24).

Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+