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GPs go forth

GP referrals being knocked back by referral management system

The BMA has said GP referrals are being knocked back due to 'arbitrary local procedures', leading to serious consequences for patients. 

It added since the rollout of the Procedures of Limited Clinical Effectiveness (PoLCE) across CCGs, a panel of GPs must apply to get certain medical procedures approved as part of an effort to save money across the NHS

Pulse previously reported that the NHS planned to save £200m by scaling back the use of 17 procedures, which has just come into force. 

However, the process is resulting in rejected referrals which has increased GP workload and risked patient safety, said BMA GP Committee executive team lead for clinical and prescribing, Dr Farah Jameel. 

It follows comments from GP and Pulse columnist Dr Ellie Cannon, who - writing in the Mail on Sunday - said she had a patient with two hernias, but whose referral was rejected because Dr Cannon did not file an application for each hernia separately.

Another of Dr Cannon's referrals to remove several growths on a patient's back was not accepted until evidence of harm for each growth was provided.

Following the article, a number of GPs said they were facing similar problems. 

Responding, Dr Jameel said: 'We need to get rid of arbitrary local criteria and the postcode lottery this creates.

'The fundamental problem is that CCGs applying restrictions in excess of those set by NHS England through the evidence-based interventions work, which was done based on a sound evidence base and following extensive consultation.

'My personal experience is that sometimes letters are not read properly, clinical information not taken as priority over criteria such as BMI. Emphasis is often more on form-filling, additional admin, arbitrary tests and making it harder to get patients a secondary care opinion.

'Where secondary care opinion is sought, with procedures deemed of low clinical value, the form-filling responsibility is often passed back to general practice, when the specialist clinician requesting the procedure may be far better placed to make the special case for funding approval.'

Dr Cannon wrote in her Mail on Sunday column: ‘I didn’t know whether to laugh to cry. It might seem trite, but this ridiculousness takes up precious time, leads to lengthy delays to treatment – and put this man at risk of complications.

‘Having spoken to fellow doctors, it seems this madness is shockingly widespread.’

She added that she exaggerated a patient’s symptoms in the past in order to secure a cataract surgery, which would otherwise have been rejected because even though the patient could no longer read, her symptoms did not meet the threshold of severity required by the panel.

She wrote: ‘What began as a sensible process to stop people getting breast enhancements and eyelifts on the NHS has snowballed into a deliberate ploy to deny genuine patients essential treatment.’

Dr Cannon noted that the PoLCE list is only growing, and that 17 new operations, some of the most common in the UK, were added just last week.

She said: 'Quite frankly, the system I am faced with is a joke. It is laughable, embarrassing and it is not fair on many patients and the GPs like myself strangled by bureaucracy.'

'The system has run away with itself – forgotten common sense and totally disenfranchised GPs and their decision making as well as causing delays and anguish for my patients.'

In response to the issue, Kent GP Dr Gaurav Gupta tweeted that he had seen a similar situation recently. 

He said: 'I have just seen this in East Kent and will be raising with CCG as this seems completely inappropriate to me.'

Another GP from Brighton, Dr Duncan Shrewsbury, commented on Twitter: 'We have a "prior approval" process for some procedures (female sterilisation, Dupuytrens contracture Tx, spinal surgery, blepheroplasty) of "low" value. Hate that it robs us of specialist assessment and opinion, let alone actual treatment!'

GP and chair of campaign group GP Survival, Dr Nicholas Grundy, tweeted that it was a 'cost-cutting given a thin veneer'. 

He said: 'Technically up to local commissioners, but if you look at STPs across the land they're all doing it, so it's one of these hideous central government mandates by stealth. As ever it's cost-cutting given a thin veneer of "evidence" in the "limited clinical efficacy": says who?' 

A former Bradford GP, Mark Purvis, also commented: 'According to local policy I had to write asking for prior approval to refer for an opinion regarding a procedure. Non-cosmetic blepharoplasty because of functional impairment, redundant upper eyelid skin intervering with vision. 

'You're made to join a game of "referral snakes and ladders" where the rules are revealed incrementally through a process of trial and error. Transitions are increasingly difficult and the poor patient can fall down the gaps between services.'

He added: 'Hospital returns referral with patient unseen asking for exceptional case committee prior approval. Exceptional case committee reply to letter requesting permission asking for consultant to confirm that there is functional impairment. Back and forwards you go.'

Readers' comments (20)

  • When something goes wrong (and it will) then the patient can sue the CCG for their unecessary delaying tactics.

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  • Another frankly stupid and mis directed initiative, which in the end will cost far more money than the few pennies they are trying to save. This has happened because we have devolved clinical decision making to "managers" directed by NHS England who in turn execute the whims of their political masters.

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  • Patients still entitled to an NHS appointment to diagnose/provide a management plan. I doubt if any CCG if challenged win on refusal for an out patient appointment. GPs are just that generalists and we do not know the ins and outs of whether a case can be made for individuality or exceptionality. After all they are procedures not consultations

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  • As mentioned above since when do we refer for a procedure? We refer for a specialist opinion-which may or may not include operative management.

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  • Vinci Ho

    We are where we are , austerity carries on
    From day one , we probably foresaw this ideology of CCG would end up like this i.e. subordinates and puppets of the NHSE and its hierarchy. Thanks to our most ‘beloved’ PM ever and the current Facebook’s head of its global affairs and communications team(well , at least the latter said ,’live by the sword , die by the sword’).
    How many of you have to ‘twist the truth’ everyday to justify the severity to deem a referral necessary everyday ? I always advise my patients to consider a private referral as an alternative if affordable these days .
    As I wrote before , the government has to make a serous decision about how this is to go forward . Boris , you can fool some people sometimes, but you cannot fool all the people all the time.

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  • this has happened to me a few times. i reply telling the refusenik that 1) i have been qualified 40 odd years 2) i have seen the patient and they have not, 3) i have advised the patient that THEY have refused to see them, and i have given the patient THEIR phone number, and advised the patent themselves to ring them for an explanation. they love trying to call the shots and bully us, but they absolutely HATE having any contact with patients ! (this also helps the patient understand the time consuming and bureaucratic garbage we have to deal with day in and day out on their behalf), this ploy hasn't failed yet - if it does, i have another ploy up my sleeve ! remember - a man with a brain who can use it, will always beat one who doesn't or can't !!!

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  • In terms of bureaucracy it is becoming more like being a family physician in the states, trying to get approval from HMOs and insurance companies. Over there it is far far worse. Could be the future for GPs.

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  • Family physicians for HMOs is directly where we are heading.

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  • It is really sad that the clinical knowledge of GPs is put in question when we refer anyone to secondary care, knowing that Primary care can't help longer and when the health of our patients, their ability to go to work or enjoy a healthy life is put under the scrutiny of Administratively lead triage systems that don't understand that we deal with human beings.... Sad times no doubt

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  • The NHS gives a bad service. It is not world class and certainly not giving service users (the patients) the choice or speed of service as it is rationalised healthcare. Patients and doctors are restricted by the NHS. You cannot use your medical or surgical skills to the full potential due to this. Lots of aspiring doctors eventually give up or go abroad.

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