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Independents' Day

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)

  • We should be charging the CCG for the extra time it takes to fill in these forms. I never agreed to do this extra work for free. Then this nonsense will stop. We need to move away from notion that GP time is free and unlimited

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  • Knowledge is Porridge

    Reasons why I will shorten my GP career:
    * Appraisal
    * CQC
    * Referral management
    * Pensions
    * Indemnity / litigation (partially fixed!)
    * Workload / staffing
    I think fixing appraisal is the most important as it would cost nothing. Referral management could be brought back into PCN's so at least we could ration our own referrals with peer support rather than being shafted by every rejection. The CQC seems to be getting more reasonable with time (and they are starved of funding and left firefighting).
    None of this would encourage a new GP to be a partner?

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  • @Knowledge is Porridge.
    The reasons I walked away at 50yrs old and now run a non-medical internet sales business:
    Old age is not a treatable illness.
    Workload (nine clinical sessions a week).
    Fed up of patients and media telling me how much I earn when tube drivers are on about the same.
    Sick and tired of listening to the sick and tired.
    Best bit about leaving is a normal working day with breaks for food and drinks.
    Worst bit is feeling guilty for not using 23yrs of experience and knowledge.
    Good luck to all who remain, you'll need it.

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  • Reason I have not walked away:
    I fear for our childrens futures.
    The concept of the NHS is worth fighting for, even if the current actuality created by this bastard government is not.

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  • DrRubbishBin

    this has been going on for years, really any excuse to decline a referral is used - doesn't meet the criteria, wrong service please refer to someone else, please provide photographs, sorry we've change the criteria whilst you were waiting for us to respond to the referral you sent 3 months. They may meet the published referral criteria but we aren't going to do it anyway, we don't have to explain why and you have no right of appeal, signed someone in an office somewhere, with a poor grasp of grammar, no clinical training and seems to think somehow they are your boss. i've had every single one of these and more.

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  • Totally deprofessionalising and undermining of trust in GPs. Will lead to increased costs and increase complaints and increased unhappiness in patients and staff. Why do doctors put up with this? Secondary care haven’t asked for it. They will know which GPs send good and less good referrals and will act accordingly anyway.

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  • several of my patients have moved house to access NHS services not available or funded in the former CCG. I think this is more common than we realise or care to admit too.

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  • |Angus Podgorny | GP Partner/Principal|15 Aug 2019 7:50am
    I fear for our childrens futures.
    The concept of the NHS is worth fighting for

    If you really do fear for our childrens' futures, you'd stop mortgaging it to increasingly and indefinitely fund a state-run failing system full of waste and abuse. And you'd encourage our kids to strive to meet life's responsibilities, inc that of health.

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  • I particularly love the patronising letters we get back to inform us that we must include something that in no way changes the appropriateness of referral.
    Or the recent one - instructing me to prescribe off-licence for an indication I've never used before. So either I prescribed off-licence or the patient has to put up with their distressing condition

    Everything seems "GP to do" but, no, you're not allowed to ask a specialist to get involved.

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  • At the end of the day, when some non clinical Scrooge blocks my referral for a patient with clinical need, it can be their responsibility to instruct the patient of such a decision, and at the same time, take on all the clinical responsibilities that I carry with me all the time.

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