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Are GP incentives an appropriate way of cutting referrals?

Paying GPs to review and reduce referrals is perfectly ethical, says LMC chief executive Dr Paul Roblin. But the GPC's Dr Simon Poole says rewarding reductions in referrals is grossly simplistic.

Paying GPs to review and reduce referrals is perfectly ethical, says LMC chief executive Dr Paul Roblin. But the GPC's Dr Simon Poole says rewarding reductions in referrals is grossly simplistic.

Paying GPs to review and reduce referrals is perfectly ethical and also essential to make best use of NHS funds, says LMC chief executive Dr Paul Roblin

As chief executive of my local LMCs group, I recently supported a request from our PCT for an incentive scheme aimed at demand management. The need for such a scheme arose when an assessment of mid-year activity data predicted Oxfordshire PCT was heading for an end-of-year overspend of £23m. The trust had identified a surge in GP referrals as part of the cause.

As a clinician, I know some of my referral decisions could be improved. I have referred too early, too late, to the wrong person and with inadequate work-up in primary care. The numbers of such errors are not large but neither are they zero. Personal tiredness, unfamiliarity with the case or patient pressure are all factors that contribute to my variable performance.

Some years ago, I acted as a referral screener for our PCT but always felt an in-house practice system would be better. That PCT system did deliver a reduction in referral rates, possibly because peer review altered referral thresholds. Key to the success of any system is communication between screener and referrer. If requests are to be altered, this must be sensitively and politely communicated one to one.

I have been critical of another local PCT that communicated by a standardised letter.

Our recent demand management local incentive scheme (LIS) was priced at £2 per registered patient (50% for 'process' and 50% for 'achievement'). The LIS was calculated to cost the PCT £1.2m at most.

The processes practices were required to implement were:

  • prospective review of all elective or non-urgent referrals
  • review of all referrals from learners, assistants and locums by named partner
  • specialty reviews of all orthopaedics, dermatology and ENT referrals
  • individual benchmarking (within consortiums and wider)
  • a checking process put in place prior to a referral decision being made.

This final point was perhaps the newest initiative and came with suggestions for introducing a brief delay at the point of each referral decision. For example the PCT suggested using 'stopping mechanisms' on IT software or the referring doctor using a set form of words with the patient that defers the final decision to refer. For instance: 'I think it would be appropriate to refer you but I would like to discuss what would be best for you with one of my colleagues. I will confirm what we are doing within 24 hours.'

For the achievement component, the PCT set a monthly target level of referral cuts for the second half of 2008/9. Payment was on a sliding scale with the full £1 per patient being paid for bringing outpatient activity in 2008/9 back to baseline levels (the year December 2006 to November 2007) and 20p paid for hitting half of this level.

Why is all this necessary? Because PCT funds are finite. Money spent unnecessarily on expensive referrals cannot be spent on health initiatives that I would value more. PCTs alone cannot make a cash-limited system work, so GPs must play a part in making NHS money go as far as possible.

And why are incentives needed? Because GPs value their expertise and need reward for the time taken to review referrals in-house. The NHS benefits from referral review, so the time involved should be paid for. It is not a bribe encouraging GPs to game at patients' disadvantage. I have confidence the vast majority of GPs know when to behave ethically and would not put their own gain before patient need.

Dr Paul Roblin is CEO of Berkshire, Buckinghamshire and Oxfordshire LMCs

Rewarding reductions in referrals is grossly simplistic and inevitably leads to conflicts of interest, counters the GPC's Dr Simon Poole

'How sick: GPs paid bonuses to not send patients to hospital.' The headline in the Daily Mail back in October was followed by commentaries in the Times and Telegraph. Such was the outcry that within days Mark Britnell, director of NHS Commissioning, had issued a stern decree to PCTs on the subject and Dr Iona Heath was warning in the BMJ of a 'devastating blow to trust within the primary care consulting room'.

Yet these reactions appeared to come as a surprise to many PCT managers and GPs who, no doubt with good intention, had agreed to engage in these schemes to reduce the recent surge in referrals, which some PCTs feared would have catastrophic financial consequences. We have for years seen the success of prescribing incentive schemes and, more recently, PBC initiatives that have produced efficiency savings and new pathways of care. So why was there such an extreme response on this occasion?

It seems any excuse will do for the media to continue their campaign of anti-GP press, but why were medical commentators also expressing concern and disquiet? What made these initiatives so unacceptable?

Prescribing incentive schemes involve rewards for changes in the way patients are treated. But this is a clinically led process involving defined alternatives to specific medications that do not disadvantage the patient. The evidence base must be robust and schemes demonstrably beneficial.

In contrast, referral incentive schemes contain independent elements where significant rewards are paid simply for achieving reductions in referral rates. Some PCTs (though it must be observed not all the schemes are the same) have shown no interest in the means employed to achieve this end and have chosen arbitrary targets entirely devoid of evidence of legitimacy.

Incentives that fund processes and reward outcome allow for investment in reviewing referrals and pathway redesign to attained a desired result. To uncouple this progression and simply remunerate an end point is a gross oversimplification of the way in which practices responsibly scrutinise referrals, and accusations of conflicts of interest are almost inevitable.

Furthermore, while acknowledging the need for financial support of practice review, practice-based commissioning has always been explicit in its expectations for the use of freed-up resources. Any savings must be reinvested in patient services. The GPC has supported this unambiguous approach and produced guidance to help GPs avoid conflicts of interest. The payment of money to practices in the case of referral incentives runs counter to transparent spending of NHS funds. This is especially important in an environment where private providers are entering primary care. Any such company, prioritising interests of share holders and profit, would inevitably performance-manage to achieve targets, risking the diminution of the professional approach that has historically been employed in general practice, and raising the spectre of patients' health budgets for the private sector to exploit.

For PBC to flourish, and more crucially for trust and integrity to remain at the heart of the consultation, GPs, LMCs and PCTs must be vigilant in protecting the principle that each clinical decision is based on what is right for each patient. Of course we have a responsibility to use NHS resources wisely, but we must also ensure individual care is not compromised and any rewards are inseparably linked to a process that is transparent and professionally led. We have a duty to not only act in a way that is beyond reproach, but also appear to do so.

Dr Simon Poole is a GP in Cambridge and a member of the GPC's commissioning and service development sub-committee

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