title: Reducing inappropriate referrals to secondary care: our experiences with the ENT Emergency clinic.
abstract: BACKGROUND
  In the current financial climate faced by the NHS, it is important that we reduce the amount of inappropriate referrals made to secondary care specialties. ENT Emergency Clinics are one-stop clinics provided by many UK ENT departments to allow more rapid access to ENT services from primary care. However, many referrals to these clinics were considered to be inappropriate, overloading the clinic and delaying referrals to more specialist clinics. We conducted a service improvement project through introduction of referral guidelines and liaising with local GPs.
  
  
  METHODS
  We carried out an initial audit of ENT referrals over a one-month period, which suggested that 31% (69/225) of referrals were inappropriate. We developed a guideline referral proforma that included six specific conditions and details of subspecialist clinics available. This was circulated among GPs and A&E doctors and backed up by hospital teaching sessions. Two months later we repeated the audit.
  
  
  RESULTS
  Following introduction of guidelines there was a significant reduction in inappropriate referrals from 31% (69/225) to 16% (28/179), p<0.01. Despite significant improvements overall, the proportion of inappropriate referrals from GPs remained higher than those from the local A&E department in both Cycle 1 (42% vs.24%, p<0.01) and Cycle 2 (23% vs. 5%, p<0.01).
  
  
  CONCLUSIONS
  Devising and circulating guideline proformas in conjunction with local education for referring doctors may help reduce the number of inappropriate ENT referrals. This simple and cheap intervention could be used more widely and developed in primary care departments in partnership with local hospitals. Our study also highlights the challenges encountered when introducing new guidelines that affect referrals from doctors in the community. Increasing opportunities for GP trainees to gain some exposure to common conditions presenting to primary care might reduce inappropriate ENT referrals in the future.
authors.affiliation: Department of Population Health Sciences and Education, St George's University of London, Cranmer Terrace, London, SW17 0RE, Department of Otolaryngology, Head and Neck Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT;, Email: smahalingam@doctors.org.uk.
authors.forename: Sridhayan
authors.initials: S
authors.lastname: Mahalingam
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT.
authors.forename: Nicola
authors.initials: N
authors.lastname: Seymour
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT.
authors.forename: Christopher
authors.initials: C
authors.lastname: Pepper
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT.
authors.forename: Philippa
authors.initials: P
authors.lastname: Tostevin
authors.affiliation: Department of Population Health Sciences and Education, St George's University of London, Cranmer Terrace, London, SW17 0RE, Department of Otolaryngology, Head and Neck Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT.
authors.forename: Pippa
authors.initials: P
authors.lastname: Oakeshott