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GP partners asked to sign off locum referrals to reduce pressure on hospitals

GPs in some areas are being asked to sign off on all locum referrals as part of incentive schemes designed to cut outpatient appointments, Pulse’s ‘Cash for cuts’ investigation has revealed.

NHS Rotherham CCG has included in its ’quality contract’ a requirement for substantive GP sign off on all short-term locum referrals to secondary care.

And in East Berkshire, three CCGs covering Windsor, Ascot, Slough and Bracknell have signed up to a locally commissioned service which encourages GPs to triage referrals – in particularly the partner or lead GP is required to review all referrals generated by locums.

The schemes have been criticised by sessional GPs leaders, who say that schemes such as these ’further the fallacy that locums are second class doctors’.

In a response to a freedom of information request on schemes to reduce referrals, NHS Rotherham CCG said its ‘quality contract’ included GP partners signing off locum referrals.

The FOI said: ’Practices will be expected to reflect on current referral behaviour within the practice and in particular to have substantive GP sign off of all short term (less than four weeks) locum referrals to secondary care. This includes an appropriate administration system signed off by the substantive GP.’

It also includes cancer referrals as part of its targets for GPs to cut referrals.

Meanwhile, in East Berkshire, the FOI response said that, under the CCGs’ incentives scheme, ’the partner or lead GP is required to peer review all referrals generated by locum doctors to gate-keep referrals’.

Dr Zoe Norris, chair of the BMA GP Committee’s sessional subcommitte, said she would hope that when a practice engage a locum GP, they do so with a colleague they know, or have sufficient background information on to feel confident in their clinical skills.

‘If there are problems with referrals, I would expect practices to discuss this with the locum.

‘A blanket rule that all locum referrals must be reviewed and “signed off” seems to simply generate extra work for partners, and further the fallacy that locums are second class doctors.

She added: ‘I am all for feedback and learning opportunities but am not sure this is the way to do that.’

Dr Richard Fieldhouse, chair of the National Association of Sessional GPs, said CCGs clamping down on locum referrals in this way were ‘missing the point’.

He said he has never seen any evidence or data that that locums are more likely to refer unnecessarily in fact locums are more likely to diagnose cancer than a practice partner.

‘By seeing different GPs, you’re more likely to spot these things,’ he said.

And he added: ‘They are forgetting there is a patient in this who has had a referral blocked.’

Dr Fieldhouse said there could be a potential issue with locums being unaware of CCG or practice specific referral pathways or service but that could be easily solved with proper induction.

‘This is the wrong solution to this problem. We have produced an online electronic induction pack for practices to use so there is no excuse.’

Dr Dean Eggitt, chief executive officer of Doncaster LMC said there was a view at the commissioner level that ‘locums refer at the drop of a hat’.

He said there may be instances where locums may not understand what is available in primary care rather than referring to hospital but this was not the answer.

‘What they actually need is education and support.’

But BMA GP committee chair Dr Richard Vautrey said it could be seen as part of peer review and is not necessarily unreasonable.

‘It is possible a locum might not be aware of the systems in place – it is a practical solution to try and ensure local systems are used.’

Readers' comments (13)

  • Some have to revisit their equality and diversity training.

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  • National Hopeless Service

    I don't see this as an issue. The NHS isnt National anymore, CCGs vary immensely in what services they do or do not offer and a locum with even a 'locum' pack cannot be expected to know the variations that exist. I am more than happy to redirect a referral to perhaps a more appropriate service o further investigate in-house.

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  • I don't object to this. It's not the same the the 'cash for cuts' scheme. There are so many different local services that it's hard enough for permanent staff to understand what is on offer.
    Redirecting an orthopaedic referral to an MSK clinic (where appropriate) or arranging direct imaging instead of referral saves having to re refer when the inevitable bounced referral comes anyway.

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  • Council of Despair

    what do you think will happen to you if you make a mistake and don't refer and something happens to that patient? do you think the family, press, friendly uncle GMC, NHSE, your CCG, CQC are going to be supportive or will they try to bury you?

    at the same time ... if you are refering inappropriately what will they do? ... they can refer you to the GMC.

    bottom line - more risk, less support and I can only see more GPs getting sent down.

    of course, there will be many who are so amazing at being GPs who will say we must always do appropriate referals and those that don't are hiding in their failures as good GPs. Really? define appropriate referal? as a locum I see different referal pathways and justification and referals are not fool proof. I insisted on a patient with a well's score of 1 to be seen based on gut instinct - the hospital gave me a hard time but guess what - she had a DVT.

    sorry but I'm going to refer what ever I feel is appropriate.

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  • A lengthy induction for a short term locum? I don't think so.

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  • We’ve reduced our referral rate by 10% in the last year. The main change, other than hard work, is that we have not required any locums in this time. I’m not saying that all locums have a high referral rate but some definitely do. If we need to use any in the future I’ll be vetting all referrals.

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  • As a locum, I find this rather insulting. I have rather more experience as a doctor than some of the partners I work for, and I wouldn’t want to be in their shoes when they block one of my referrals without seeing the patient, and harm or perceived harm comes to the patient. This sort of scheme is money for work that has already been done. If I don’t know the local referral pathway, I ask a partner or secretary. Although only the other day, it seemed that I was the only one in the practice who knew the local pathway, from my work in other practices... after a considerable amount of searching and phone calls, the referral form I knew was needed was eventually produced!

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  • Haha, I am a Locum and let partners sign or reject referral. Buck will rest with partner if patient complains, I can always say I have done my Job, correctly or incorrectly. If you as patient dies, its partners responsibility now who didn't sign my referrals.

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  • doctordog.

    If I were a locum, I would find this insulting.
    Confidence in the abilities of a locum has to be in all areas.

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  • Cobblers

    Couldn't give a monkeys. If a GMC registered GP wishes to overrule my referral then good luck.....enjoy the responsibility.

    As it surely won't be my neck that is presented to Madame GMC Guillotine.

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