In England, clinical commissioning groups (CCGs) are spending millions of pounds on schemes that screen patient referrals from GPs to specialist services, reveals an investigation by The BMJ.
Overall, two in five of the CCGs that responded to The BMJ's requests for information use a referral management system of some kind, and a third of the schemes are provided by private companies.
Some of the schemes aim to reduce costs, while others hope to improve the quality of referrals. But almost three quarters of CCGs which responded were unable to provide evidence that showed whether or not their scheme had saved money overall.
The move sparked concerns from clinicians and The BMA, which warned that CCGs risked repeating mistakes of predecessor organisations by commissioning schemes of questionable effectiveness.
The BMJ sent freedom of information requests to all 211 CCGs in England. Of 184 CCGs that responded, 72 (39%) said they currently commissioned some form of referral management scheme to help manage outpatient activity in local hospitals.
The findings show:
93 referral management schemes in operation across 72 CCGs, with some CCGs operating more than one scheme.
32% of schemes are run by private companies, 29% in house, 11% by local NHS trusts, 11% by NHS commissioning support units,10% by the voluntary sector, and 7% by local clinicians.
69% of CCGs with schemes disclosed operating costs. These CCGs combined have spent at least £57m on schemes since April 2013.
Only 14% of CCGs provided figures to show that the scheme had saved more money than it had cost to operate, and 12% showed that their schemes had not saved money overall.
74% of CCGs with schemes failed to supply figures to show whether money had been saved overall.
20% of CCGs commissioned a new scheme since April 2013, and the same proportion are continuing to commission schemes previously set up by primary care trusts.
Richard Vautrey, deputy chair of the BMA's GP committee, said "[CCGs] are leaping at these schemes without any clear evidence of benefit and that they're just hopeful that it might reduce their costs. It is a very, very short term approach to healthcare management. We need to see much more evaluation...and not just keep making the same mistakes year after year."
The lack of evidence provided to The BMJ on savings was a particularly concerning finding, he said: "As public bodies, there should be an expectation on every CCG to account for what it's doing."
But some of the schemes that enabled local specialists to provide rapid advice and guidance to GPs "can be very helpful", explained Vautrey.
Graham Jackson, co chair of NHS Clinical Commissioners, the membership organisation which represents CCGs, said referral management was just one mechanism that local groups use to try to manage demand for services.
"In many cases they provide a useful and effective role which is more than a redirection service," he said. "CCGs will balance the cost of commissioning with the benefit they provide to GPs and patients in terms of peer review, education, caseload management and choice."