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GPs to be asked to 'peer review' all referrals

Exclusive CCGs are formulating plans to scrutinise practices' referral systems after a leaked NHS England memo showed they have promised to incentivise peer review schemes in order to reduce referrals by 30%, Pulse has learnt.

Pulse has learnt that NHS England wrote to CCGs in May, asking them to ensure that there is ‘clinical peer review of all referrals from general practice by September 2017’, and this should be done on a weekly basis.

The May 2017 guidance ‘Elective Care High Impact Interventions: Clinical Peer Review’ says that there will be 'significant additional funding' for commissioners to establish GP peer review schemes this year.

Pulse has seen an email from NHS Bedfordshire CCG to commissioners on plans to scrutinise GPs' referral schemes.

It states: 'As you will be aware there is now an ask from NHS England for us to ensure we have 100% coverage of prospective peer review in practices. The attached document sets this out. [The local area team] needs assurance from that we have a plan to do this and how that will be rolled out across practices.'

The email includes an attachment from NHS England on plans to incentivise these peer review schemes.

The NHS England report says: 'Significant additional funding is being given to regional teams in 2017/18 to roll out and spread interventions and schemes that will help CCGs to deliver a slower growth in referrals.'

It states that good practice would be for GPs to review each other’s new referrals, at least once a week, to ensure that ‘all options are explored and that patients are seen and treated in the right place, at the right time and as quickly as possible.’

But the guidance also makes clear that that the process ‘should not be established as an approval process’ and the ‘referring GP retains responsibility for the patient and makes the final decision’

This comes after Pulse recently reported on a pilot scheme in the North East of England, under which GPs must get approval for routine referrals from a team of GPs and GPSIs.

NHS England claim that ‘published literature identifies internal peer review as a positive intervention with benefits to patients and GPs and it could also reduce referral rates by up to 30%’.

But Professor Azeem Majeed, professor of primary care and head of the department of primary care and public health at Imperial College London, warned that referral management schemes can sometimes ‘result in delays in referrals’, particularly when assessors are ‘not fully aware of the background to the referral’.

He said: ‘To carry out effectively, clinical peer review requires adequate time and resources.

‘Given the current pressures on NHS general practice in England, this scheme may well end up as a tick-box exercise rather than something that will improve patient outcomes and NHS efficiency.'

GPC clinical lead Dr Andrew Green said: 'I wish NHS England put a tenth of the effort they expend on reducing pressure on hospitals into reducing pressure on GPs, which is the area of the health service with the biggest growth in workload.

'We are used to seeing un-referenced claims such as "could reduce by up to" in adverts for antiwrinkle cream and I am surprised to see such language in an official document.

'It is important to be aware of the lost-opportunity costs of schemes like this, if we assume an hourly weekly meeting that would be equivalent to removing 1000 GPs from the English workforce, GPs we don’t have.'

An NHS England spokesperson said: "Clinical peer reviews are a simple way for GPs to support each other and help patients get the best care, from the right person, at the right time without having to make unnecessary trips to hospital. More than half of CCGs have already implemented some of peer review system, with Luton seeing an 8% drop in hospital referrals, and the latest NHS England guidance will help ensure best practice is shared to remaining local commissioners."

A spokesperson at NHS Bedfordshire CCG said: ‘The executive team at NHS Bedfordshire CCG is currently in discussion with clinical leads on the implementation of the Clinical Peer Review system.

‘Details of the agreed system will be advised in due course.’


Readers' comments (31)

  • As a Scottish gp I look on with increasing incredulity at some of the crackpot ideas emanating from CCG's in England.Every gp with any experience will know that there are very varied and complicated social ,psychological,physical and cultural reasons why a gp makes a decision to refer.Without actually knowing and seeing the patient it is almost impossible to make a decision about the need for the referral especially with financial implications bearing down from accountants.As an aside,who will scrutinise the referrals of nurses,pharmacists,physician assistants and opticians when they take over the bulk of gp work.?? Will this be left to a diminishing group of gp experts(sic) who are prepared to take " the fall" for any medicolegal disasters?.

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  • For my fellow older GPs!

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  • National Hopeless Service

    Did this a few years ago. It didnt change anything, we even saw a slight rise in referrals. It was just another pointless NHS meeting so we stopped after 3 months.

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  • AlanAlmond

    GPs to be asked to pretend nobody is ill..that'll save a bundle ..genius

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  • Obviously it has to be internal as no one in their right mind would veto another GPs referral , the indemnity issue is immense.
    So this really a workload shift, and as such needs to be paid for.
    I am quite happy to refer 20 patients and then spend an hour consulting/considering whether they should be sent in the first place. I would expect the full 20 to be referred eventually, whilst picking up a cheque for £250 in the process.
    Of course, if the CCG wants to see a reduction in referral activity I will simply volunteer a cool 30 patients for consideration to the vetting procedure, and end up with 25 being referred in the end. And picking up a cheque for £375 in the process, for the 1.5 hrs it takes me.
    Of course the CCG might not want to pay private rates, so I might tell them to do it themselves.
    Fun and games set by non doctors.

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  • I am 66 and I have just finished just over 13 hours at the surgery having had an early surgery at 0700. I am retiring at Christmas as I just cannot take any more. I have always loved my work until the last few years and I am now retiring at the lowest point career. I was going to try to stay longer as the Practice is already 4 doctors down and I am very concerned about its future. However, I feel that if I don't go now I am likely not to live to enjoy my retirement. The NHS has been destroyed by politicians and managers.

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  • We audited our referrals a few years ago. Interesting to see others referral letters but actually a complete waste of time. I, and others in our practice, do refer patients at their request even if not medically essential because that's what they want and the patient is always right. Until this changes, like CAMHS declining referrals, this floodgate will always be open. Don't refer at your peril.

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  • Agree completely with Meg-if they want to see a specialist I refer.Nobody at Nhs England will support you for saying no,so sod the gatekeeper role-they are wide open for me and all totally justified on the basis of patient choice.

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  • My CCG suggested that we ask all referred patients if they have private medical cover. Well yes I guess you can make a utilitarian case for this but the fact that there were equally compelling opposing ethical analyses was completely and utterly beyond them.

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  • It'll be fairly easy to bypass by pushing as much as possible through the 2ww system. As the threshold is set at an incredibly low 3% PPV, the CCGs will find filtering these impossible. FTE indemnity is at 10k/GP so it doesn't make sense to reduce referrals any further as we are already at unsustainable levels of risk.

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