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PCTs impose referral caps to tackle debts

By Gareth Iacobucci

Exclusive: GPs are being hit with unprecedented caps and restrictions on their referrals by NHS managers, as the financial crisis gripping the health service leads to huge pressure to reduce spending on acute services.

A Pulse investigation reveals a host of trusts are launching drives to clamp down on GP referrals, with some imposing arbitrary limits on practices.

The issue has thrust general practice onto the political agenda in the aftermath of the general election, with the Conservatives – including a newly elected GP MP – claiming their plans for GPs to hold real commissioning budgets would prevent trusts forcing clinicians to crudely cut referrals.

Pulse's investigation shows that cash-strapped trusts have drawn up a range of measures aimed at cutting acute spending – including NHS Buckinghamshire, which has imposed a referral cap on GPs in order to tackle a huge budget deficit.

As a result of the restrictions, introduced last September, the trust has seen a 17% drop in referrals, and is expected to break even financially this year from a £7.5m deficit in 2008/9.

The scheme has involved publishing GPs' referral rates on a traffic-light scale, which Dr Paul Roblin, chief executive of Berkshire, Buckinghamshire and Oxfordshire LMCs, described as a ‘naming and shaming' exercise.

A spokesperson for NHS Buckinghamshire insisted the changes were not purely driven by financial needs, and said: ‘Referral allocations have been put in place to ensure patients are treated in the right place, at the right time, by the right person'.

Similarly NHS Sandwell said it had agreed ‘thresholds for referral between GPs and consultants' as part of moves to transfer activity into community settings.

Pulse's survey of 45 trusts and health boards across the UK found that almost two-thirds have some form of referral management scheme in place.

Among these were NHS Westminster, whose new scheme monitors activity in areas such as ENT, dermatology and orthopaedics, and NHS North Lancashire, which is aiming to reduce referrals in procedures ‘of limited clinical value'.

Elsewhere, NHS Portsmouth has set itself a target to reduce referral rates by 2%.

Local GPs are furious at proposals by NHS South Birmingham for practices to seek the trust's permission before referring for conditions such as varicose veins, hysterectomies, grommets and back pain.

Dr Bob Morley, a GP in Birmingham and executive secretary of Birmingham LMC, said the LMC would fight hard to resist such an arrangement: ‘To expect GPs to ask permission of the PCT prior to referring a patient is wholly unacceptable.'

But Dr Chris Spencer Jones, director of public health at NHS South Birmingham, said: ‘The LMC's views have been incorporated into our approach, which is clinically led. If this scheme goes ahead less than 1% of referrals will be affected.'

The investigation comes after Pulse recently revealed plans to impose sanctions on GPs in Harrow if they did not refer patients to a new community-based service instead of to hospital.

GP Dr Sarah Wollaston, who has been elected Conservative MP for Totnes, Devon, said the Tories' policy of handing GPs real commissioning budgets would reduce the prevalence of such controversial schemes.

Dr Wollaston said: ‘If GPs have more control over commissioning, we would see more common sense return to the NHS. It's this tsunami of targets that we have to get away from.

‘There is a finite resource in the NHS but those decisions should be based on clinical need. We need to return clinical decision-making to clinicians.'

GP referral activity under the microscope

• ENT
• Dermatology
• Orthopaedic services
• Minor surgery
• Emergency admissions
• Nursing home admissions
• End-of-life care
• Ophthalmology
• Audiology
• Cataract assessment
• Gynaecology
• Oral glucose testing
• Varicose veins
• Back pain

Newly-elected Conservative MP Dr Sarah Wollaston: if GPs held commissioning budgets, clinical decision-making would return to them Newly-elected Conservative MP Dr Sarah Wollaston: if GPs held commissioning budgets, clinical decision-making would return to them Referral management schemes across the country

Use our interactive map to see how PCOs across the UK are clamping down on and even capping GP referrals.

To view the map, please click here.

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