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The waiting game

GPs offered up to 50% cut of savings generated by slashing their own referrals

Exclusive GP practices in five areas of the country are being offered controversial ‘profit share’ agreements that see them paid up to half the savings if they refrain from referring their patients to hospital.

The controversial payments – up to 50% in some cases – are revealed as part of a major Pulse ‘Cash for Cuts’ investigation looking at how local health organisations are taking the pressure off secondary care.

But the payments have been called a ‘dereliction of duty’ by GP leaders, who argue that cash incentives should have no place in the consulting room. And they come after the RCGP raised concerns about the effect of referral restrictions on patient care.

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Read all about our investigation here

Pulse revealed one profit-sharing scheme last year for reducing prescribing in care homes, but this is the first report of similarly designed to reduce non-urgent GP referrals. Pulse’s ‘Cash for Cuts’ investigation received freedom of information responses from 181 CCGs, with a quarter offering some kind of financial incentive designed to cut referrals to specialists.

Eleven of these were offering a direct incentive based on GPs changing their referral behaviour, with five ‘profit sharing’ schemes, including:

  • NHS Coastal West Sussex CCG told Pulse it is offering groups of GP practices 50% of the savings on any reduction in elective activity from the previous year
  • In West Leicestershire, GP federations receive 30% of savings made on first elective referrals
  • NHS Vale of York CCG offers GP practices a ‘gain/share’ arrangement for dermatology referrals and ‘a proportion of any savings achieved’
  • NHS Enfield CCG in north London says 50% of any cost reduction for GP-referred outpatient attendance ‘will be shared with the locality’
  • NHS Wolverhampton CCG says it is considering a profit-sharing scheme.

The CCGs say that the funding is to be used on patient care, and that the schemes have been implemented to improve the quality of referrals (click here for their full responses).

Other areas were offering payments for big reductions in elective referrals, including a £1.4m scheme that sees practices paid £5 per patient for cutting GP referrals by at least 10% - described as ‘unsafe and needs urgent review’ by the local BMA GP representative – and one including cancer referrals.

Dr Peter Swinyard, chair of the Family Doctor Association said the profit-share schemes were ‘bizarre’, adding: ‘From a patient perspective, it means GPs are paid to not look after them. It’s a serious dereliction of duty, influenced by CCGs trying to balance their books.’

Former RCGP chair and south London GP Professor Clare Gerada said: ‘We should be concerned about any incentive to alter behaviour that is not in patients’ best interests.’

Referral incentive schemes have proved controversial in the past, with Pulse reporting plans for GPs to peer review all referrals and NHS England scolding CCGs for offering incentives to GPs for cutting down the number of urgent cancer referrals they make.

The BMA’s GP Committee chair Dr Richard Vautrey said: ‘We’ve raised concerns about these schemes where there is an arbitrary target.’

GPC clinical and prescribing lead Dr Andrew Green said: 'This idea is the unflushable stool in the toilet of desperate measures.'

Dr Amanda Doyle, co-chair of NHS Clinical Commissioners and chief clinical officer of NHS Blackpool CCG, said: 'Any initiative or scheme that aims to manage referrals from primary care to secondary care must of course put patients, not finances, at the heart of decisions and should be about making sure referrals are appropriate and not just about reducing the number.

'Directly linking payments to reductions is not appropriate and NHS England, as the regulator, would take a role in addressing that circumstance.'

Dr Jeremy Mayhew, clinical lead for primary care at NHS Coastal West Sussex CCG, said: ’The agreement focuses on reducing the number of inappropriate or incomplete referrals, when a patient can be waiting several months only to be bounced back to their GP practice – causing a delay in care for that patient and a cost to the NHS system.

’To encourage GP practices to take the time to review their referrals and share this learning, GP practices are able to access half of the money that is saved within the NHS system by reducing these inappropriate referrals.

’After approval by the CCG, this money is then spent on improving access to their services for local people and the development of local community services; no GPs receive payment, directly or indirectly.’

For a full list of CCG responses, please click here


Readers' comments (34)

  • This raises the same ethical issues as did GP fundholding-remember that?

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  • Clear conflict of interest. As well as been a shameful proposal, it yet again illustrates the completely different and divergent mindsets of the bureaucrats 'managing' the NHS to those of physicians. A general misunderstanding of how the practice of medicine functions.

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  • By undermining patients' trust in GPs' motives this will actually cost the NHS more in the long run. It is recognised that one of the reasons that the NHS makes such "efficient" use of specialist services is the GP primary care role e.g. not everyone with headache needs to see a neurologist. The ability to do this is based on the patient trusting the GP's judgement and accepting that if a referral is not necessary then it really is not necessary. Research shows that continuity of care with a trusted GP reduces referrals, investigations and medications - but based on rational medicine not financial incentives. The way to reduce unnecessary hospital costs is to invest in proper general practice, ensure enough GPs to have the time for patients and to provide continuity of care. Sensible referring is part and parcel of being a good GP and should be what we do anyway, not something we only do if we are paid. If it's not happening in places then that should be dealt with through continuing professional education. It is a false economy to think that undermining the essential foundation of general practice - trust in the doctor-patient relationship - will save the NHS money - rather it will cost the NHS massively! Only people who have never been GPs or forgotten what it's like to be a GP could possibly think these financial incentive schemes are the answer and not part of the problem.

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  • If anything, GPs refer too few patients, not too many.

    Cutting referrals presumes the opposite and misses the point of system underfunding.

    "Incentivising" GPs to cut referrals is unethical, immoral and stupid. Whoever exhumed this zombie needs retiring.

    In the light of Dr Bawa Garba, we also now know that GMC will hang us out to dry for failures that we have no control over, regardless of the systemic issues.

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  • Well said Marie-Louise Irvine. Absolutely right.

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  • AlanAlmond

    Why not cut out the middle man and give the money ‘saved’ direct to the medical negligence industry.
    I spent my afternoon wading through mandatory child protection modules on line. What struck me was there are so many ‘best practice’ recommendations for GPs to refer to secondary care..and here they are paying what is basically blood money to hedge your bets, take a punt and hope everything turns out ok. Your GMC hearing won’t be taking that into consideration when you get strung up for gambling with peoples wellfair for cash
    Feckin disgusting

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  • Vinci Ho

    A riddle:
    We sell our code and morality for money.
    We pay regulators to persecute our ‘sins’ .
    Yet, we are to receive mental training like soldiers in Afghanistan.
    What are we?

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  • How on Earth is this policed? Surely if you document that a plan for a patient is referral you have to refer? Or do you give a list of patients to the CCG you think needed referral but “wink wink” I fudged the notes and didn’t refer? Can I have my £5000 now please?

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  • Financial incentives work. You only have to look at the history of general practice over the past 15 years to see how it has successfully reinvented itself in response to government incentives.

    At its inception, the GMC recognised this as well. It took a very serious view of doctors who “split fees“, a practice that involved doctors sharing fees which the GMC recognised would lead to a conspiracy against patients, and clinical decisions being made on financial grounds rather than clinical necessity.

    These incentive schemes are no different from fee splitting. They also offer fees to influence doctors referral decisions. It may be that some patients will benefit, as CCGs have maintained. It is almost inevitable that some will suffer.

    My heart sinks at having to point out the obvious. Why has it become necessary to highlight policy initiatives that are so blatantly unethical? This measure is so awful that people should be out on the streets

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  • Regretting being so economical with my referral rate to date, as there’s no leverage to cut it further. Tempted to avoid the same mistake with scrips and admissions, which might be coming next.

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