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How the 'cash for cuts' referral schemes work

Pulse’s ‘Cash for cuts’ investigation has revealed a number of CCGs are allowing GPs to profit share the savings made from cutting referrals. Here are all the details

NHS Coastal West Sussex CCG

Practices (working in groups of around 30,000 patients) receive 50% savings on any reduction in elective activity made from the previous year.

This includes all referrals to any qualified provider contracts such as dermatology and community ENT as well as locally commissioned services such as wound closure, PSA monitoring, minor surgery and spirometry.

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.’

NHS West Leicestershire CCG

GP federations receive 30% of any savings made on ‘first referrals’. The CCG says: ‘Through the work done in this scheme to improve the appropriateness and timeliness of referrals, identify and spread best practice and efficiency, and to refer patients to the “right place”, we will improve the experience of, and the outcome for, the patient.

‘One indicator of this improvement will be the reduction in the number of clinically unwarranted and unnecessary referrals, particularly into secondary care. However the focus of the scheme is about improving the quality of clinically appropriate referrals made, not reducing referrals in general.’

NHS Vale of York CCG

GP alliances receive a proportion of any savings achieved ‘against agreed trigger points’, based on their dermatology spend per head of weighted population compared to the total CCG spend.

The CCG says: ‘The aim of this service is to improve dermatology provision for the patient at a primary care level and prevent inappropriate referrals to secondary care.

‘This can lead to a number of benefits, including: assurance that patients are seen in a timely manner by the most appropriate service, thereby allowing secondary care to concentrate on the most complex patients; improved patient experience by delivering consistent outcomes; delivering appropriate care closer to home; and improving dermatology knowledge and skills within primary care.’

NHS Enfield CCG

The CCG plans to reduce referrals to bring practices in line with the North Central London average referral rate. It says 50% of any cost reduction for GP referred outpatient attendance (from 15/16 baseline plus planned growth) ‘will be shared with the locality’.

Practices are also given funding to implement better processes for referrals.

The CCG says: ‘GPs are required to reinvest savings in areas to support improvements in patient care and proposals for reinvestment are approved by the CCG.

‘The CCG is very clear that the focus is on quality of referrals and ensuring referrals are clinically appropriate, which also includes reducing referrals where clinically appropriate.’

NHS Wolverhampton CCG

The CCG has proposed that member practices receive a proportion of the savings generated through a reduction in referrals from an agreed baseline. A proposed payment mechanism is currently being developed with finance, the CCG says.

NHS Barnsley CCG

Practices receive £5 per patient for cutting referrals by a minimum of 10% across a range of specialties – cardiology, colorectal Surgery, ENT, gastroenterology, general medicine, general surgery, gynaecology, hepatobiliary & pancreatic surgery, paediatric ENT, paediatric trauma and orthopaedics, plastic surgery, trauma & orthopaedics, upper gastrointestinal surgery, vascular surgery. The CCG has set aside £1.4m for the scheme.

The CCG says: ‘Ensuring treatment is based on the best clinical evidence and improving historical variation in access is essential for us locally. We invest in a comprehensive Practice Delivery Scheme which increases investment in capacity and infrastructure in primary care to meet increasing demands, in turn practices work with us to improve care and outcomes for Barnsley residents. This includes an ambitious but achievable 10% improvement in clinically appropriate referrals.

‘Financially, it is an effective use of local resources which will improve patient experience and outcomes and increase investment in primary care in line with the Five Year Forward View commitments. Primary and secondary care clinicians have been involved in the development of this scheme.’

NHS Rotherham CCG

Under the CCG’s ‘quality contract’, GPs receive up to a maximum of £3.36 per patient – a third of which is linked to hitting a target to reduce first outpatient appointments to cluster average or by 1%.

When asked whether the target included urgent cancer referrals, a spokesperson says: ‘The quality contract encourages appropriate clinical management of referrals and no referrals are excluded from our data.’

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Readers' comments (1)

  • 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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