Five questions you should ask before offering referral incentives
Dr Simon Poole advises GP commissioners on how to avoid a potential conflict of interest
1. What are referral management schemes and why are they important?
The term ‘referral management scheme’ is ill defined, used to describe a number of activities. In the past we have become familiar with PCTs analysing referral rates and also encouraging the use of specific pathways to attempt to reduce referrals. CCGs are now, however, introducing new schemes known as primary care incentive schemes or primary care investment schemes, which go a step further. As GPs we ‘commission’ every time we refer people and in austere times we have a responsibility to use resources wisely. As GP commissioners we will inevitably wish to consider variations in referral rates and it is entirely legitimate to do so, and to engage in discussions with practices as to why such variabilities may exist. However, recently many incentive schemes have become much more clearly focused on reducing overall rates of referral.
2. How can we avoid a conflict of interest?
The GMC’s Good Medical Practice is clear doctors must make the patient their first concern. Appropriate investigations and referrals are a necessary undertaking. We are also obliged to use resources wisely. The GPC strongly urges any doctor considering commissioning or participating in incentive schemes that reward practices for arbitrary reductions to carefully consider the potentially serious professional and ethical implications.
Such incentives are not grounded in clinical evidence but are motivated by the need to cut costs. Furthermore, it is the GPC’s view that they introduce unacceptable conflict into the doctor-patient relationship. Good commissioning uses clinical evidence to analyse the quality of services and improve patient care. Resources should be used to fund new care pathways and services or, where appropriate, reward improved outcomes. For example, many successful prescribing incentives schemes have incentivised the use of generics over brands, an efficient use of resources with no detriment to patient care. The new quality and productivity indicators in the QOF are another example: financial rewards to practices arise following analysis of referrals, and are not dependent on specific targets of financial savings or reduced referral rates. The GPC has consistently expressed concerns about such incentive schemes, and has asked the GMC to investigate the schemes (see their response in the box).
3. How should commissioners ask for feedback about schemes?
If a practice has any doubts about any incentive scheme being offered, they should address them to the CCG with the help of the LMC. Incentive schemes are ultimately voluntary, and CCGs should not place practices under undue pressure to participate. On a more positive note, a referral management scheme might be a good opportunity for a CCG to find out whether resourcing for continued professional development such as protected learning times could improve the quality of referrals.
4. How can we draw on expertise from other CCGs or national bodies?
Where I practise in Cambridgeshire the peer review schemes are beneficial to patients and safe – they don’t reward practices directly for reducing referrals or cutting costs. I didn’t commission them myself but they have been in place for some time. When designing the scheme the PCT listened to recommendations put forward by the LMC, which made sure that the scheme was consistent with our understanding of the ethical principles.
5. How do the schemes benefit patients, GPs and the CCG?
Under a well-planned scheme, commissioners have the possibility of improving outcomes and to make care more cost effective, releasing money to be spent on other services. With increasing quality of referrals, patients may receive better care and avoid unnecessary visits to hospital.
In particular, if practices are resourced to undertake audits and peer reviews, then GPs will have the opportunity to identify areas where improvements can be made and perhaps consider individual learning needs. GPs are frequently willing to undertake such work to work as part of professional development.
What the GMC says
We accept that financial incentives can provide a legitimate way of influencing or changing doctors’ behaviour.
Such incentives might be used to improve quality of care… to encourage the responsible use of NHS resources.
Incentive schemes should be focused on encouraging behaviours that will be of overall benefit to a community of patients, or to individual patients.
They must also ensure that:
• patient safety is not compromised
• patients continue to receive the clinical care to meet their individual needs – they should not encourage a uniform or blanket approach to all patients with the same condition
• incentives are paid in relation to decisions or outcomes for large groups or populations of patients; they should not directly reward decisions relating to individual patients.
In general, we expect that incentive schemes should specify that payments arising from the scheme should be used for improving patient services and not for the financial benefit of individual doctors.
Source: Letter from Dr Peter Rubin to Dr Laurence Buckman, 25 September 2012
Dr Simon Poole is deputy chair of the GPC’s commissioning and service development subcommittee and a GP in Cambridge