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Should NHS budgets dictate a GP's own medical practice?

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I was dismayed to see recently that the local Trust has started advertising its tariffs for blood tests.  An email to local GPs with the details would have sufficed, but instead they’ve casually dropped the prices in bold type onto ICE, the online path requesting system.

I discovered this having worked up an anxious young patient with abdominal pain. It was persistent, unusual and causing concern. I launched ICE, checked the appropriate boxes and clicked proceed. Then, something new: each test had a corresponding cost displayed. And a total: £36.75.

I reviewed the patient in question with his results after a fortnight of mebeverine (it helped).  His bloods, disappointingly given their expense, were entirely normal. (‘Of course they were’, the dinosaurs will cry). Some £36 of NHS resources spent in eight clicks of a mouse, and not so much as a borderline CRP. 

I suspect that GPs of my generation may have a little more sympathy.  We have been trained in litigious times. One of our first lectures at Sheffield was given by a Texan medical negligence lawyer. ‘So remember, folks, y’all step outta line and I’ll sue your ass,’ was his closing line to a room full of mortified first years. From the off, we’ve been told to exercise caution and expect the unexpected. 

We shouldn’t undervalue the reassurance some patients derive from normal tests. Telling them that, in one fell swoop, you’ve ‘ruled out diabetes, infections, blood loss, thyroid problems, Crohn’s and a gluten allergy’ offers enormous relief. On the flip side, choose the wrong patient and you reinforce unhealthy behaviours: so what’s next doctor, whole body MRI?

Admittedly, we live in challenging times, amidst cuts and cost-savings. I’m no advocate of the carpet-bombing approach which skips past the core skills of history and examination. The plan from our Trust is to make GPs think twice before requesting serum kryptonite. It works too. As soon as I was confronted with the financial reality of my request, an internal dialogue emerged: Do you really need an ESR and a CRP? Does this really sound like coeliac disease? Does he need any bloods at all? 

Here’s a question though: to what degree should budgets dictate individual medical practice? The consultation is an intellectual challenge. Should pound signs on path requests really be allowed to interfere? 

They already affect prescribing: try to issue certain medicines and Script Switch suggests something cheaper. Should the fact that an LFT costs a fiver deter the doctor from his inclination? 

I worry that bottom lines are topping agendas, and GPs are being subtly extracted from their safety nets. With my patient, I always suspected it was ‘only IBS,’ but now I’m much more certain. More importantly, so is he.

Tom Gillham is a GP in Hertfordshire and Specialty Doctor in A&E. You can follow him @tjgillham.

Readers' comments (2)

  • Hadrian Moss

    An excellent article and I agree with your worry this is a slippery slope we are on.
    Perhaps the developers of ICE could be encouraged to add a READ code pick list of potential diagnosis the clinician is considering with a corresponding financial column indicating recent costs for a missed diagnosis when taken to court?
    CRP £5 Missed Crohn's £250,000

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  • Sorry, I miss the connection between CRP and Crohn's? Otherwise I like the idea of attaching prices to tests and am thinking of introducing it in my lab. There is a move to actually pay the full cost of pathology test instead of the old 'block contract'. This will inevitably lead to heart attacks in the CCGs and a 'we must reduce our Pathology spend' kneejerk reaction. You have been provided with the information to do so.

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