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!'
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 (pt & GP) of specialist assessment & opinion, let alone actual treatment!— Duncan Shrewsbury (@DuncanShrew) August 5, 2019
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.'