Focus on... incentives to cut referrals

29 Oct 08

‘You must act in your patients' best interests when making referrals,’ reads the GMC’s Good Medical Practice guidance.

So far, so good. Acting in their patients’ best interests is the essence of what all GPs spend their working lives striving to achieve.

But the GMC guidance continues: ‘You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you …. refer patients.’

It’s this clause that strikes at the heart of a controversy currently raging around general practice.

GPs are not naïve. They have long been used to coming under pressure to perform a balancing act between doing what might, strictly speaking, be in an individual patient’s best interests – and paying heed to ever-growing pressure on finite NHS resources.

The latest row centres on whether a spate of referral incentive schemes being drawn up by financially stretched PCTs are merely the latest example of that tension – or whether such schemes break new ground in unethical behaviour.

Financial chaos

Now GPs up and down the country are arguing over how far they should be prepared to accept inducements to help PCTs tackle a huge and as yet unexplained spike in referrals which threatens to plunge trusts into financial chaos.

Take GPs in Torbay, where the PCT is offering practices payments of around £8,000 per thousand patients, if they meet its targets to reduce spiralling hospital activity.

Practices can earn maximum points if they achieve an 8% reduction in GP referrals, bring down the number of emergency bed days by 4% and pull off a 10% reduction in admissions for a huge array of acute and chronic conditions, ranging from COPD, heart failure and diabetes complications via dental problems through to influenza and ENT infection.

The coup de grace though is the unfortunately worded section which offers GPs top points for ‘increasing the proportion of all deaths that occur at home by 4%’.

Dr Peter Moore, a GP in Torbay, Devon, defends GPs’ right to take part in such schemes.

‘It’s offensive to suggest GPs would not refer a patient for the sake of a few bob,’ he says. ‘Providing there’s no clinical reason to go to hospital, it’s not unethical to explore alternatives. And if we do extra work then it’s not unreasonable that our businesses are reimbursed for it.’

PCTs are desperate to head off a financial crisis, which is being in large part caused by a 16% increase in GP referrals in the first quarter of the year compared with the same period last year.

Last week Pulse reported that trusts across the country are facing an overspend on hospital activity which will total - at conservative estimates - well over £100m.

Many GPs themselves vehemently oppose elements of the referral schemes, which they say conflict with their fundamental responsibility to put patient care first.

NHS Hampshire, which is facing a £23.7m overspend, is another of those to resort to drastic action, in its case offering £200 per week to an average sized practice just for ensuring the GPs sit down and review referrals and share their findings with the PCT on a weekly basis.

So desperate is the PCT’s financial crisis, that any practice that keeps its year-on-year referral rate rise down to 20% will get a further £1,000 under a sliding scale of incentives. Practices that simply manage to keep their referrals down to the same rate as last year will get a maximum £4,000 reward.

The PCT has made clear that the money must not go into GPs’ pockets and will have to be reinvested in one of a specified range of ways, such as diagnostic equipment, computers and prescribing initiatives.

Nevertheless, many local GPs have baulked at the idea of taking money not to refer patients. Wessex LMC voted 14-11 against backing that part of the incentive scheme – although it did come down in favour of the plans for practices to get paid for weekly internal referral reviews.

The GMC has warned that GPs who agree to incentive-based referral reduction schemes may be walking a thin line.

‘There is a fine balance between using financial rewards to promote effective use of resources, good clinical practice and or public health policies, and inappropriate use of incentives that limit or restrict patients,’ says a spokesperson.

‘Doctors must make the care of their patients their first concern. We accept that there may be benefits for individual patients, and for the community, if patients can be safely and effectively diagnosed within general practice and it is reasonable to encourage doctors to do so. However, it is unacceptable for doctors to delay or withhold a referral on the basis of the financial benefit they might accrue.’

Dr Ethie Kong: 'It's not a bonus payout or anything like that'

GPC chair Dr Laurence Buckman has been predictably less measured in his condemnation of referral incentive schemes, branding them ‘morally dubious and ethically disturbing’, while shadow health secretary Andrew Lansley told the Commons last week: ‘It is inefficient and unethical to pay GPs to refer fewer patients to hospital. If patients find out that their local health bureaucracy is paying their GP not to refer them to hospital they will be rightly outraged.’

With such outrage being bandied around, perhaps it’s no surprise that the national press has jumped on the story as the latest stick to beat GPs with.

‘How sick! GPs paid bonus NOT to send you to hospital’, declared the Mail on Sunday front page headline last week, while the Sunday Telegraph took an indignant tone over an ‘investigation’ which mostly re-hashed already known facts.

Many GPs feel furious that they are being blamed for problems not of their making.

NHS Oxfordshire is offering practices payments of up to £10,000 to review referral procedures and a further ‘bonus’ of £10,000 for bringing down referral rates. The scheme could cost the trust £1.2m – a huge outlay, maybe, but just a fraction of the projected £22m overspend it faces.

Early discharge

GPs in the area say they are being accused of greed because of a situation caused by failing secondary care policies. Minutes from a recent Oxfordshire LMC meeting note: ‘Most GPs feel that the hospital is discharging patients too quickly and this means that GPs are having to refer the patients back into the system.’

Dr Ethie Kong, a GP in Willesden, north west London, whose practice comes under NHS Brent and is signed up to the trust’s referral management scheme, says GPs have been unjustifiably vilified.

‘The idea is a good one – if you commission effectively you can use the savings to do something else. But in order for practices to do that you need to give them support,’ she says.

‘It’s not a payout or a bonus or anything like that – the money goes on things like paying for locum doctors so we can ringfence the time to discuss referrals with GPSIs, venue hire for our PBC cluster meetings, and a full-time analyst to audit referrals for the cluster.;

She adds: ‘The proof is in the pudding. The trust looks at all our audits to make sure the money is being well spent. Our dermatology cases are now all screened by a GPSI and there have been no disasters. In that case referrals have gone down, but we’re not refusing to refer outright. Our gynaecology referrals have gone up – but they were all clinically needed.’

There is as yet little evidence to go on as GPs argue over whether the schemes will even be effective in bringing down referral rates without compromising patients’ safety.

Professor Martin Roland, director of the National Primary Care Research and Development Centre, is an author of one of the few previous pieces of research on the subject. His study concluded in August 2007: ‘Financial incentives to encourage GPs to reduce referral rates can be effective, but this is a high risk to both necessary and unnecessary referrals.’

Balancing the books

But Professor Roland is more ambivalent in his assessment of the latest wave of incentive schemes. ‘Anything which is able to encourage GPs to make sure the patients they refer get the best care without needing to go to hospital is a good thing. But something that looks crudely at numbers is potentially damaging for patients,’ he says.

‘But I don’t think it is unethical. GP referrals are expensive so it’s a good way of cutting costs. Balancing books is the main driver behind these schemes.’

Yet balancing the books and GPs’ duty to act as advocate for each and every one of their patients always make uneasy bedfellows. The debate has already raged as high as the House of Lords, with Baroness Masham of Ilton questioning whether GPs were being ‘bribed’ not to send patients to hospital.

She was answered by none other than health minister Lord Darzi himself, who insisted: ‘GPs are not being bribed; they are paid to make appropriate referrals based on their clinical judgment to places where patients will receive the right treatment in the right place.’

For its part, the Department of Health insists such schemes are valid. ‘It is quite right for the local Primary Care Trusts affected to examine GP referral patterns in their area,’ says a spokesperson, while quickly adding the proviso that ‘GPs should base their referral decisions on what is clinically appropriate’.

Torbay’s Dr Moore concedes the incentives system is open to human error and not without significant potential legal repercussions. ‘The system would be unsafe if in the hands of a bad GP,’ he concedes. ‘But we can’t run the NHS on the basis of what bad GPs might or mightn’t do.’