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GPs forced to get approval before referring patients to hospital

GPs are being forced to wait for specialist advice before referring patients to hospital under a new pilot programme in the North East of England.

The Clinical Assessment and Peer Review (CASPeR) system, which is being rolled out across Darlington, Stockton-on-Tees and Hartlepool this month, aims to reduce 'variations' in patient assessment and care as well as ease the 'considerable pressure on local hospitals'.

GPs will have to wait up to two days before receiving an answer in some cases.

NHS Darlington CCG and NHS Hartlepool and Stockton-on-Tees CCG said that they ‘recognise the importance of delivering high-quality care to patients’ but added that 'they have to do this using NHS resources wisely'.

But local GPs said this was simply a 'very expensive paper exercise'. 

Under the scheme, a team of GPs and GPSIs will 'assess routine referrals from GPs within two days' and will offer advice to 'go ahead in the usual way or consider alternative treatments or tests first'. Urgent referrals will not be affected.

GPs will be able to appeal decisions in cases where the referral has been rejected.

A spokesperson said: 'The new system should support GPs with a specialist opinion on management of a patient and will help to ensure that they are treated in the most appropriate way first time based on best practice guidelines.'

But Professor Ahmet Fuat, a Darlington GP and professor of primary care cardiology at Durham University, warned that this will have little benefit while increasing GPs' workload.

He said: 'The evaluation team will only have a referral template and definitely no access to clinical systems or notes. I cannot see how a GP without specialist knowledge or access to notes will be able to give advice to a GP not to refer, or be able to redirect referrals appropriately in anything but a handful of cases.

'I just don't agree that this anything more than a very expensive paper exercise, which is very unlikely to cut referrals or be cost effective, and will have a huge impact on workload for our already overstretched and stressed secretarial staff.'

Another local GP, who did not wish to be named, was able to 'say with certainty' that there are 'a lot' of Darlington GPs who are 'very unhappy with what we are being asked to do with CASPeR'.

The GP said: 'By far the biggest problem we currently have in Darlington is a serious and extremely worrying lack of GPs, with no solution in sight, and a situation that is likely to get worse.

'The recruitment of local GPs to help manage CASPeR can surely only be at the expense of our already overstretched workforce and may well make it more difficult to attract GPs to Darlington.'

This latest pilot follows a 2012 study, published in British Journal of General Practice, revealing that referral management schemes do not reduce the number of patient referrals and can be expensive.

But the spokesperson for the CCGs said: 'CASPeR is based around similar systems which have already started in other parts of the North East, which have shown to be of benefit. We believe the cost of the system to be an effective financial model given the increased quality of care the service will deliver for patients.'

It comes as grassroots GPs have instructed the GPC to launch a ‘national debate’ with Government and health bosses on what care the NHS should stop funding, while vast numbers of CCGs ration treatments such as IVF, and as NHS England is looking at what over-the-counter and 'low-value' items it can ban GPs from prescribing.

Readers' comments (34)

  • Easy solution to this. Ask for GMC numbers of clinicians who designed this process and refer straight to GMC.

    Note the use of word 'variations' in care - this is the 5 year forward view in action:

    look at the originators of the MP/ACO project

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  • Ehhhh.
    Hang on, wait a minute.

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  • Many areas have a referral support service now. There is a wide variation in the quality of referrals and often people are referred for things that are treatable by a GP. An example is the patient with a cough for several years with globus where the GP has only tried a PPI,done CXR etc and the GP simply needs advice to suggest the patient uses gaviscon (otc of course) and using it correctly. Then if no improvement in two months consider referral.
    In our area before the rss was setup we had ENT constulants regualrly reading through the referrals and writing back with advice as an alternative to seeing a patient... this was for the 15% of referral where the letter was poor with insufficient info so the consultant is asking for more info or the the info in the letter was good and the consultant could confidently offer advice. This has now been rolled out so GP and consultants do it together.
    As a result the quality of referrals has improved.

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  • They tried this in North Durham and planned to role it out to the whole of Durham when the CCGs merge. However they analysed the results and the scheme reduced referrals by

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  • we rejected this approach - why? - because it doesnt work and is non-contractual. It's also unsafe as GPs refer sometimes becasue they dont have the skills to do tests or interpret them - just telling them to do tests they cant interpret really isnt helpful

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  • Mark Howson - 50% of globus is due to sychological issues - until MUPS is addressed by Psych and IAPTS services GPs will continue to refer

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  • Sitting by the pool in Tuscany last month a friend said that the nature of progress is just that things get more complicated.

    Looking back over my immersion in GP and GP Education over the last 30 years it is hard not to disagree.

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  • Just keep referring and clog them up with appeals then they will stop it.

    Don't let adminbots destroy your career by accepting a rejection for patients only to see YOU.

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  • doctordog.

    So long as patients are told the reason for the critical delay in their diagnosis and management.

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  • It is bizarre that in an age where no clinician would consider not practicing evidence based medicine, colleagues working for CCGs are happy to implement non-evidence based management decisions. There has been much research published about referral management, and the Kings Fund has published some quite sensible advice. Referral management as described is costly, has limited (if any) long term benefits, and delays patient care. However there is evidence that audit and benchmarking does improve referrals...

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  • Anyone who looks at GP referrals will tell
    you the vast majority are OK.
    However there are some appallingly poor ones - mostly inability to frame the actual problem and lack of relevant information. The lack of a suitable local service also rapidly becomes apparent.
    Shining a light on a referral area produces imptovement in referral quality but numbers less sure about.
    None of the contributions seem
    to document changes in quality or identification in referral pathway gaps. This needs redressed.

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  • The MDOs should sort this out and simply refuse to indemnify GPs who don't have appropriate secondary care support. The problem would end overnight.

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  • 'Clinical Assessment and Peer Review (CASPeR) system'

    I wonder if they flirted with calling it the 'Clinical Referral Assessment and PEer Review' system.

    Perhaps a standard letter to patients whose referrals have been rejected:
    'My clinical judgement is that you need to be seen in clinic X. I have been barred from this by Dr XXX GMC xxx employed by x CCG. The chair of the CCG is Dr yyy at The Sleppleafy Practice. He works on Tuesday and Thursday morning. I suggest you join his practice and ask to see him personally as he is a far better GP than I am and has the skills and capacity to deal with your problem without you attending hospital.'

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  • Politicians will find ways to bail out hospitals but never general practice.
    GPs therefore have a moral duty to refer more to hospital in order to increase overall funding for the NHS.

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  • At least it's done by GPs. Ours is nurse run. Slavish adherence to guidelines and (mainly) funding criteria. Recent delay to hysteroscopy and diagnosis/treatment of endometrial hyperplasia because insisted on GP arranged ultrasound before gynae referral. No hip/ knee opinions without a really bad Oxford score. Not to mention ridiculous appointment booking for those that do get through whereby 50% are told they are too early or too late to book an appointment or that there aren't any appointments and they should- you guessed it- go back to their GP.
    But soon there won't be any independent thinking GPs left and all will be run by noctors with a computer algorithm. That will sort out all those 'variations'

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  • Odd that this should be news - my local CCG has had a system like this for some time.

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  • We all have different levels of skill and knowledge, so there will always be variations in what different GPs refer. Plus, our secondary care colleagues already have the option to write back and suggest alternative options.

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  • The thing that would help me reduce my referral rate is a system that sticks up for me more when things go wrong. Instead we have a system where GPs making an honest mistake get hauled over the coals of multiple jeopardy, ombudsman, GMC, manslaughter charges etc. This does nothing to persuade me to accept clinical risk hence I refer more. An example would be, 10.08, in my book you can not assume persistent cough is reflux, they need a chest CT, maybe lung cancer...

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  • The whole point of the 'variations' argument is that it is a cover story for deep cuts and also transfer the risk of clinical decision making even more to GP's.

    The only benefit from Brexit it that NHSE wanted to flood the market with primary care practitioners - this will not happen now.

    Hospital consultants are within their right to reject a referral if they think its inappropriate - rarely done though.

    Again referral management pathways have not been tested in court yet and it'll be interesting when they are.

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  • I'm assuming most GPs in this area have GMS contracts. The GMS contract clearly states that GPs can refer at the point they (the GP) decides that specialist care is needed.

    That is all.
    The GMS contract does not say that GPs have to prepare everything for secondary care, organise the tests they may want to see or abide by referral guidance systems.

    If the CCG want this type of system they should be encouraging (not forcing) GPs to use it by way of an enhanced service (primary care contract). Price it correctly and give GPs the choice.

    For example I am allowed to follow the DVT LES and give patient some clexane in the surgery etc, and I get a LES payment for doing so. If I cannot be bothered with that I could admit them to hospital and let the hospital manage the DVT. The LES is priced fairly so I tend to use it.... but I have a choice.

    If they said £50 per referral that uses the new system, I think many practices would use it. If it were just 5 pounds I think most practices would refer in the standard way, as they are entitled to, under their GMS contract.

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