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Independents' Day

Bribery doesn't always work

Copperfield is feeling insulted rather than incentivised by PCT offers of tenners to slash referral rates

Copperfield is feeling insulted rather than incentivised by PCT offers of tenners to slash referral rates

It's often said that the best way to get reluctant GPs to toe the line is by paying them to do so. Because it's true. After all, there was a time when I'd rather have eaten glass shards than screen diabetics for depression - but now I check their misery score, dish out the SSRIs and, most important of all, tick the QOF box. Not sure it helps them, but it cheers me up no end.

Bribery doesn't always work, though. Because there are times when GPs can't, or won't, play. Take the current furore over referral rates. PCTs have decided that handouts encouraging GPs to slash referrals will be more productive than hand-wringing over why rates have rocketed in the first place.

Fine. Except that I'm feeling insulted, not incentivised. I don't refer patients for fun. Except, of course, for the slightly unnecessary referral of the frequent and persistent attender who refuses to take, trust or respond to my treatment, and who is therefore doing my head in.

The determinedly dissatisfied

This at least gives me a sabbatical, and the pan-orifice-oscopy I arrange for the determinedly dissatisfied sometimes has the effect of changing their attitude, too.

An alternative would be to send these patients into some kind of limbo, analogous to the holding patterns of aircraft denied landing slots: a place where they are no longer my problem, and they experience the illusion that something's happening when it's not. Hang on - that's physiotherapy.

That aside, I refer only what needs referring. The PCT can wave tenners in front of my eyes - but it won't blind me to the fact that I know what can be achieved on Planet Primary Care, and when to cut my losses.

Besides, only a simpleton would assume that the current inflation in referral rates is all down to GPs. What about hospital gaming, aimed at squeezing as many referrals as possible out of the same patient? And guidelines which patronisingly assume GPs can do sod all but refer - or which are so complex that doing sod all but refer is the only sane option?

And increasingly stringent targets, where reducing blood pressure, cholesterol, HbA1c and so on to the desired level means banging your head against a brick wall, or referring so that someone else can have that pleasure? And raised public expectations in an increasingly litigious society, which leads to relatives saying 'If anything goes wrong with my dear old mum, I'll sue your testicles off' - which is quite an effective way of securing an appointment with a geriatrician.

Anyone who knows anything about general practice will tell you that the decision to refer is a complex intellectual process, not a simplistic behaviour. Add in the external pressures currently pushing open the gate we GPs are supposed to be keeping and you have a situation where we're trying to play chess while being mugged with a baseball bat.

The fact that PCTs believe a few financial carrots might solve this situation suggests two things. One, that they haven't a frigging clue what goes on in primary care. And two, that they need an urgent psychiatric referral. But, hey, I might not bother.

Dr Tony Copperfield is a GP in Essex. You can email him at tony


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