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GP commissioners impose locum referrals 'ban'

By Andrew McNicoll | 11 Nov 2011

Exclusive GP commissioners are set to impose a ‘referral ban' on locums in a bid to drive down hospital referral rates, under controversial plans tabled by a clinical commissioning group (CCG).

Board papers from Southwark Clinical Commissioning Committee reveal plans to launch ‘a ban on GP locum referrals' in a bid to tackle ‘significant over activity' by local GP practices. The papers show that the CCG hopes to ‘launch the ban', which will see GP partners asked to police locum referrals, at locality meetings being held this month.

But sessional GP leaders attacked the ‘patronising' plans – which they said would isolate locums by implying that they have lower clinical competence than GP partners.

The papers state: ‘Month 5 GP practice level activity reports indicating the significant overactivity will be sent out on Monday followed up by visits to practices. AB stated that he will discuss [the] request re a ban on GP locum referrals…and then hopefully launch the ban at the locality meetings.'

Sessional GP leaders agreed that peer review of referrals could be a positive step, but warned that singling out locums would ‘disenfranchise' sessional doctors and see them ‘set up to fail.'

Dr Steven Bassett, deputy chair of the BMA sessional GPs subcommittee and a GP in Swansea, South Wales, said: ‘All GPs need to look at our referrals, but to single out locums and use of terms like "ban" on referrals is unacceptable and unjustified. The contractual status of a doctor has no bearing on the clinical competence of practitioner.'

Dr Richard Fieldhouse, chief executive of the National Association of Sessional GPs and a locum GP in Chichester, said: ‘GPs all working together on referrals can be sensible but to single out locums is patronising and sends the message that GP partners are somehow above sessional doctors.'

‘You will end up with a lot of disenfranchised locums who are being set up to fail.'

GPs from Southwark Clinical Commissioning Committee were unavailable for comment.

In a statement, the CCG said: ‘The suggestion refers to GP partners quality assuring referrals by locum GPs to ensure referrals are directed to the most appropriate service. ‘

‘This approach will be discussed with the chair, vice chair of the Southwark Clinical Commissioning Committee and the Local Medical Committee Chair before any implementation.'

READERS' COMMENTS

Anonymous, GP Partner,
11 Nov 2011
We tried this in our practice - all locum referrals were vetted. It increased partner workload and made no difference to referral rates!!
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Julian Hall, GP Partner,
11 Nov 2011
In my opinion locums and sessional doctors generally do not appreciate the pressures put on practices by PCT's and CCG's when keeping to health care budgets and driving down prescribing and referral costs. In my experience, they dont attend the same meetings with PCT/CCG representatives that GP principles do, and are therefore not subjected to the pressures of balancing patients' health care need with rationing services. I do not doubt that in the main, locums are clinically competant to make correct clinical judgments, however they may not be familiar with the local referral pathways and may not fully utilise less costly community services. The problem this will cause for principles is the time consuming process of looking through the locums' referrals. If principles had the time to do this, they wouldn't have felt the need to book a locum in the first place.
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Anonymous, Sessional/Locum GP,
11 Nov 2011
As a recent locum who has now become a principal I think this is a ridiculous state of affairs. What is now being stated is that a locum doctor is working in a reduced role and not capable of making a decision to refer. How about barn door referrals such as rapid action chest pains, or 2 week waits?? We have a policy now where we have a daily referral meeting and our regular locum attends on the day he performs a surgery. All doctor referrals are vetted, be they partner, salaried, locum or trainee (we have ST3/ST2's working)Again this is CCG meddling cuasing duplication of work which I doubt will reduce referrals by much.
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Hussain Gandhi, Sessional/Locum GP,
11 Nov 2011
Though I do not work as a sessional at present, I do feel the above is insulting to sessional GPs. It will have significant effect on the clinical relationship developed between a sessional GP and patient, especially if it is a regular sessional for the practice and undermine the role performed by the GP. It also inhibits that 'second viewpoint' that can be achieved by having someone not associated with the practice have a role in individual clinical care for a patient.
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Julian Spinks, GP Partner,
11 Nov 2011
This would mean that patients of a single-handed GP who is away and covered by a locum would be denied timely treatment.

I hope that those leading the CCG have good defence cover.
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Anonymous, Salaried GP,
11 Nov 2011
So locums and sessional doctors are c*** doctors are they. Patronising twerps! They are happy enough to use us when they want to stay in bed at night! Maybe they need to look more closely at their own practices in their cosy little privatised cartels.
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Anonymous, Practice Manager,
11 Nov 2011
This will put locums out of work - what practice is going to employ locums and then have to see any patient that may need a referral - Aside from this what an insult to question the professional opinion of a doctor just because they do not happen to chose to join a practice permenantly, either as a employed salaried GP or partner. Doctors should stand together on this one and defy this.

Patients would support the action because you would be doing this on their behalf.
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Anonymous, Practice Manager,
11 Nov 2011
This smack s of desparation on behalf of nhs southwark - glad we don't live in this area
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Diana Smallwood, Sessional/Locum GP,
11 Nov 2011
I have worked as a partner, singlehanded, salaried and as a locum since starting general practice in the 1970s. I was a GP partner when the GP training system began. I think this suggestion is insulting and possibly illegal. Peer review is a good thing but to imply locums are not as good clinically as any other GP status is playing a dangerous game. I have often been a 'fresh eye' when a locum and referred when their usual GP has overlooked things due to familiarity with the patient. I agree, do we have to ask permission for 2ww and fast track cardiac and TIA cases etc? What message does this send to the patients?

And thank you practice managers for your support. Perhaps you know more about the calibre of the GPs as you see us locums more than the drs who employ us.
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Edoardo Cervoni, Private GP,
11 Nov 2011
If this is true (which I doubt), it would be certainly worthwhile considering cost-effectiveness of such a measure and what the lawyer would think when, inevitably, a delayed referral resulted in a delayed important diagnosis and management, particularly if the locum GP flagged the potential risks.
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Samir Naseef, Sessional/Locum GP,
12 Nov 2011
This is interesting. Am I right to assume that Southwark Clinical commissioning Committe has done their home work and has the evidence that the locums there are the culprits for high uncontrolled inappropriate and not cost effective referrals. They have found out their locums are not up to date with current pathways, that they are not sensible and they refer left and right. Well done Southwark CCC. You have cracked down one the major issues of the QIPP.
I just hope that their proposal is based on evidence to start with and wouldn't it be better if locums are involved, kept up to date with the referral pathways and the NHS reforms if they are to blame? I am glad I don't work in that area and feel with locums who do
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John McDonald, Sessional/Locum GP,
14 Nov 2011
Ridiculous. I retired from full tme GP/Trainer 2 years ago. One of the advantages of being a locum can be patient unfamiliarity which obligates reading summary and previous consultations often by different partners. I have more time to keep up to date and read patient's notes. This isn't cost saving, it's simply cost delaying.
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Anonymous, PCT,
14 Nov 2011
Samir Naseef, Sessional/Locum GP,

Probably not but its easier to blame locums that to look too closely at their own referrals.
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Edoardo Cervoni, Private GP,
12 Dec 2011
The alleged locum GPs referral over activity is potentially interesting, but I am not sure where it may be coming from. It does not reflect my personal experience, albeit it may be suggestive.
We actually do not know the current Principal GPs referral rate per consultation.
Most practices would struggle gathering this datum correctly as referral must have been coded correctly to return a meaningful search using current primary care software.
I have reviewed the bibliography on the matter, and when grouping all the papers published since 1981, it appears that referral rate per consultation has been of 5.05±1.24%.
For who it may be interested, my most recent referral rate (last trimester) over a randomly selected surgery and 3 months period was, by pure chance, exactly 5.05% (out of 475 encounters). I am a locum GP and I have found no publications addressing referral rate of locum GPs. I would welcome further research on the topic.
However, always from reviewing the literature, and applying some common sense, it seems to me that variation in referral rates remains unexplained, and that many factors may be playing up such as availability of specialist care, psychological variables (GP less tolerant of uncertainty or who perceive serious disease to be a more frequent event may refer more patients). There is even a paradox: GPs with special interest may even end-up to refer more to the specialty of interest.
To summit up, I do not want to think for a second that the Southwark Clinical Commissioning Committee was serious about the ban...
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