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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)

  • We were doing this over a decade ago. Whilst it's 'cosy' to have lunch with your colleagues and go through referrals there is always a reason why a patient is referred - social context etc or sometimes just that 'nagging worry' when - as an experienced dlinician - you know that something is not right. It may not fit the referral criteria but we've been highly trained to manage uncertainty and sometimes that looks like a referral. A GP Update (Red whale) cancer update 18 months ago talked specificially about that "nagging feeling" and encouraged referral.
    Total waste of time and money in my experience - referral always still goes off

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  • It's the outcomes of the referrals that matter. Analyse this then work backwards to determine if the referral was appropriate or not. Also take into consideration whether the patient was seen for the same reason by a different doctor earlier and why weren't they referred then.
    I did this as an audit exercise when I was a partner - myself + five other partners.
    What I found out was that it was practically impossible to change someone's referral habits.

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  • Would it help if someone screened all the 'tried- before' and batshit crazy ideas to emerge from NHSE and CCGs before they cause harm?

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  • Indemnify us and we'll do it otherwise you can go **** yourself

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  • Crazy double bind for GPS - face bankruptcy or imprisonment - for the gratification of ignorant and incompetent management?

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  • Rogue1

    Its just a game. We simply send 30% more referrals, so the original number of patients get through to see a specialist.

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  • Rogue1

    I also like the idea of sending 'nearly everything' through the 2week wait. As the threshold has now dropped to 3% risk, the majority of referrals can be worded to fit that criteria. It would be a brave doctor /admin staff to reject those, although it has happened to us (with dire outcomes!)

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  • It's a brilliant cost-saving exercise! As evidence, I present the orthopaedic referral for a patient with bleedin' obvious advanced osteoarthritis who wanted to discuss knee replacement surgery and which my younger partners picked out as "inappropriate" because I hadn't requested an MRI scan first, relying instead on that outdated history-and-examination rubbish. Is that the sort of thing NHS England has in mind?

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  • there is some evidence that if done correctly - which includes finding time and funding - this can be seen as a very positive quality exercise by the referring doctors especially if its done retrospectively in a peer supported way with careful attention paid to how the feedback is given by whom and about what. what you dont do is obsess about guidance, have non gps giving the feedback - do it in a negative critical way. of course anything nhs e implements will be done badly and for the wrong reasons... so im against it.. but there is some merit...

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  • I am against it because I do not have any spare time to implement this. Each day still has only 24 hours in it.

    The decision to refer is made in the already crammed 10 minutes. Give me longer consultations and perhaps i will be able to consider each referral with a bit more time, when the patient is still with me. Trying to second guess my referral motives much later in time is useless, demeaning and demotivating.

    Walk a mile in my shoes first.

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