Open Access Open Badges Research article

Impact of a referral management “gateway” on the quality of referral letters; a retrospective time series cross sectional review

Ally Xiang1, Helen Smith1*, Paul Hine1, Katy Mason1, Stefania Lanza1, Anna Cave1, Jonathan Sergeant2, Zoe Nicholson2 and Peter Devlin2

Author Affiliations

1 Division of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PH, UK

2 Brighton and Hove Integrated Care Service Limited, Fourth Floor, 177 Preston Road, Brighton BN1 6AG, UK

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BMC Health Services Research 2013, 13:310  doi:10.1186/1472-6963-13-310

Published: 14 August 2013



Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care.

This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters.


Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral).


Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of ‘past medical history’ (from 71% to 84%, p < 0.001) and ‘medication history’ (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods.


Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement.

General practice; Referral letters; Quality improvement; Peer review; Referral management