Exclusive GP practices in some parts of the country are being placed under ‘special measures' by their clinical commissioning groups (CCGs) and required to justify every future referral decision.
Several GPs have even reported that a practice in their CCG has been excluded because of concerns over its performance and use of resources, amid claims from RCGP chair Dr Clare Gerada that some local commissioning leaders have engaged in ‘cherry-picking'.
One CCG in four has challenged a local practice over its above-average referral rates, A&E admissions or prescribing costs, according to a new survey conducted by Pulse and commissioned by management consultancy Kurt Salmon and solicitors DMH Stallard.
The findings follow the GPC's warning last month that ‘unacceptable' measures were being used to ‘micro-manage' practices, and a Pulse investigation that found one CCG had told GPs to limit their referrals to as few as four a week.
Some 27% of GPs surveyed said a practice in their CCG had been challenged on its performance over referrals, prescribing or A&E use, with half a dozen reporting a practice had been excluded as a result.
One in six GPs of 400 respondents said that where they worked high-performing practices with low use of resources and those in affluent areas were grouping together at the expense of lower-performing or more deprived neighbours.
A practice manager, who asked not to be named to avoid causing ‘any problems for the GPs here', said her practice in Yorkshire had initially been excluded by its CCG and had only been admitted after it appealed.
‘The original reason given was geographical,' she said. ‘But equally, we work in an extremely deprived area so "to balance the consortium" we weren't allowed to stay where we wanted.'
Dr Gerada, a GP in Kennington, south London, said: ‘I predicted GP practices with the most deprived populations and the worst health would face problems, and we are beginning to see it happen.
‘This cherry-picking ends up widening health inequalities as poorer populations are excluded. I am very worried about the grounds on which CCGs are excluding or challenging practices.'
Dr Annie Farrell, a GP in Liverpool, told Pulse her CCG had called GPs from her practice into twice-weekly referral management meetings.
‘Our practice has been marked by the CCG as a high referrer for planned care and it has created some difficulties,' she said. ‘It does not necessarily follow that high referrals mean we are treating our patients in the wrong way – maybe we are better doctors than those who are referring less, but that doesn't seem important any more. Because we are labelled as a "high referrer" we are having referral management meetings twice a week and all our referrals are discussed to find alternatives. It is really time-consuming.'
Dr Simon Bowers, Matchworks Shadow CCG chair, said all 93 GP practices in Liverpool were ‘working towards understanding their referral behaviour' and the additional workload had been accompanied by ‘significant investment'.
Dr Dennis Abadi, a GP in St John's Wood, north London, said the Central London Healthcare CCG was regularly challenging local GPs on prescribing costs.
‘There are outliers in our CCG and they are challenged as to why that is, but outliers are not necessarily a bad thing,' he said.
CCG chair Dr Ruth O'Hare said: ‘Our goal is to make sure all our GPs are prescribing appropriately.'
GPC negotiator Dr Chaand Nagpaul said that monitoring every referral from a practice should be a ‘last resort'.
‘It would be a "special measure" in an exceptional circumstance. It would not an appropriate starting point,' he said.
