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GPs left to manage third of urology referrals under CCG cost-cutting drive

Exclusive A new scheme in the South West of England designed to streamline primary care referrals to urology specialists has seen nearly a third of referrals sent back to GPs to manage, leading to fears around patient safety and workload. 

The scheme at NHS Northern Eastern and Western Devon CCG has required GPs to carry out further investigations usually done by the specialist, and in some cases tests they were not equipped to do.

The CCG said that it was satisfied an initial six-week pilot of the scheme showed it was safe to be rolled out more widely - with the prospect of expanding the approach to other specialties.

But Devon LMC leaders said they are concerned the pilot was not properly evaluated and the scheme is putting cost-cutting above patient safety - with no extra resources available to GPs to carry out the work. 

Under the scheme, consultants from another area – Gloucestershire – carry out an initial review of all GP urology referrals, to judge whether the patient should be booked in for a specialist outpatient appointment, or should be sent back to the GP with a management plan and recommendations to order tests directly.

The CCG said that sending patients back to GPs with a management plan speeds up the process for patients, as they do not have to wait weeks for a face-to-face appointment with a specialist.

But Dr Mark Sanford-Wood, from Devon LMC executive, told Pulse the LMC was concerned the CCG's evaluation 'related almost entirely to cost reduction, and appeared not to give sufficient consideration to safety and quality or to increased GP workload'.

Figures given to Pulse by the CCG show that during the first six weeks, 141 (30%) of all referrals were sent back to the GP with a management plan, with the majority of those requiring the GP to do a trial of therapy or investigations, including pre- and post-voiding ultrasounds and CT scans.

A total of 15 patients had to be re-referred, and the CCG said further evaluation is underway to find out whether this related to GPs not being able to carry out the requests, and whether it had delayed any diagnoses or treatment.

However, it said that after reviewing the six-week pilot it had ‘instructed those undertaking the referral review not to return those kinds of investigations for primary care… for the time being’. 

The CCG announced over the summer that it was rolling out the scheme to the rest of the region, to evaluate if the approach is of benefit and 'whether this should be expanded to other specialties'. 

Dr Sandford-Wood said that the LMC was aware that GPs were still being sent back referrals with orders to arrange tests that were not available to them because of local protocols, and that GPs were too busy to carry out all the follow-up appointments with no extra resources.

He said: 'The overall drive is to move the first and even in some cases the second outpatient appointment into general practice. For each of those outpatient attendances saved they could use the money to reinvest in general practice to do the work, and they aren’t doing that – it is, first and foremost, a cost-saving measure.'

Dr Sandford-Wood said the prospect the scheme could be expanded to other specialties was a 'massive concern'.

He said: 'Having done this in urology they may decide there are many other specialties where they could do this, thereby significantly cutting their outpatient referrals and costs. That is of massive concern to the LMC, primarily because it would crush practices and destabilise core general practice services.'

NEW Devon CCG said in a statement it was 'aware of the concerns’ from Devon LMC but that these highlighted ‘potential outcomes of such a service rather than what has actually taken place'.

It comes as Pulse reported earlier this month that NHS St Helens CCG was forced to back down from cost-cutting proposals to ban all non-urgent referrals during the winter.

Readers' comments (19)

  • Cant be core GP as they havent given the GPs the choice as how they manage the patient.
    Bet they havent considered the cost of removing this money from the trusts either.
    As well as the cost to GP, or whether GPs are competent to do it.
    As for a 6 week trial - really? That's way too short.
    So many things wrong here hard to know where to start.
    What should have happened is the Trusts to triage - organise the tests themselves then seen the patients.

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  • Of course most GPs can clinically manage the work, assuming they have access to the necessary investigations, but we do not have the time.

    When will we be given a new payment per consultation contract? There is no limit to what hospitals and CCGs can dump on General Practice because of our ridiculous contracts

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  • Peter Swinyard

    I have a feeling that we haven't heard the full story of this yet - is the LMC telling the CCG that they cannot impose this, only suggest? What happened to funds following the patient?
    I think many of us would be prepared to do a fuller work-up for some referrals if we had the time and skills and facilities. But as generalists, we are not micro-hoapitals and often are stymied by refusals of our requests for special investigations.
    Suggestion above of local triage much better. But we must retain the right to refer for management, treatment and diagnostic help. We are, after all, obliged to do so.
    Is this another instance when the GPs on the CCG board have become supine? Are they going to go public and tell us what they are thinking?

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  • This concept of giving a management plan rather than seeing the patient is reasonable and I guess we do it informally all the time e.g. After discussing a pt by phone. However I agree 6 weeks is a short evaluation, work load on GPs is not considered and GPs do not have access to things like bladder scans.Even if a payment to GPs is added to the scheme how long before this is taken away and we are left '' just part of the job"
    The 2004 contract was supposed to get rid of the " John Wayne contract - aGPs got to do what a GP has to do .
    CCG GPs have gone native and do not represent grass root GPs

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  • This is pretty weak by the LMC. They and local GPs should have foreseen that this would innevitably result in addtional GP workload and should have been clear from the start that additional funding for general practice was required to cover it.

    I'm afraid to say that our profession can be our own worst enemy. Why are we agreeing to do more work for free??? Who in their right mind would even consider this???

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  • Bob Hodges

    I'm not sure I see the problem. The referrals are screened and you get 'an opinion' from a specialist, without the patient having to traipse up to the hospital to be told they need to do 'x' or 'y' and then come back. If they've done 'x' or 'y' before they see a urologist - everyone's a winner.

    Some of the referrals that specialists get are a bit shoddy as well. GPs CAN do more than they chose to before referring SOME of the time.

    I'm sure that Gloucestershire CCG will be 'sharing the love' from any savings made in future with practices via the 'primary care offer' ES which is pretty fair.

    COI- One of my mates (a urologist) is doing the advice and guidance service.

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  • general idea reasonable aside from where the funding for the work goes, but surely checking which investigations gps were or were not allowed to request themselves according to local protocols would have been an important detail in the initial protocol?

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  • 'I'm sure that Gloucestershire CCG will be 'sharing the love' from any savings made in future with practices via the 'primary care offer' ES which is pretty fair. '

    Ho ho ho ho!
    As if!

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  • Bob Hodges

    I was actually being serious.

    They generally do 'share the love'. Our CCG has a tract record of investing in ESs in recognition of the additional work. It's a virtuous cycle.

    You should come to work in Gloucestershire..........

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  • Bob - you do - most CCGs don't as they don't have the cash.
    We don't have time to do more in GP even with the money.
    No reason why secondary care couldnt do the tests themeselves without seeing the patient.
    Not convinced by advice and guidance - scheme round here looking at it - my guess is it will increase our workload (there is no GP payment here).

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