Last year’s revelation from Pulse that CCGs in England were attempting to cut GP referrals to hospitals by offering money to practices was met with horror across the profession.
Pulse’s investigation into the issue found CCGs were paying practices to meet specific referral-reduction targets – and in some cases giving GPs money linked to the level of savings achieved, through profit-share arrangements.
GPs questioned the morality of such an approach – and some called it a ‘dereliction of duty’.
Now Pulse can reveal there has been a dip in the number of these schemes – but at least six are still in operation, four of which have been introduced within the past year.
On top of this, the new GP contract endorses a ‘shared savings’ scheme for primary care networks from 2020/21, to reduce pressure on A&E, and cut avoidable admissions and unnecessary appointments.
So should GPs feel relieved that there are fewer of the much-criticised schemes? Or is there a worry that this approach – now being promoted as ‘shared savings’ at a national level – will become more prevalent?
Pulse’s investigation in 2018 found 11 CCGs were paying practices that met specific referral-cutting targets.
Five of them offered ‘profit-share’ arrangements that meant GPs were paid according to the savings achieved by cutting referrals – up to 50% in some cases.
At the time GPs said they acknowledged CCGs were under enormous pressure to bring down secondary care costs. But they warned that having a ‘target’ – or receiving income based on reducing activity – affected trust in GPs’ clinical decision-making and undermined their relationship with patients.
Some said the schemes were ‘influenced by CCGs trying to balance their books’ and that ‘from a patient perspective, it means GPs are paid to not look after them’.
Following the outcry, there was action. The Labour Party called on the health secretary to rule out such schemes. A petition against the incentives gathered 100,000 signatures on the day it launched.
A year on, Pulse has found around half of those schemes have been dropped.
But new initiatives have also been introduced, suggesting CCGs have not been completely deterred, despite the warnings.
Overall, out of the 174 CCGs that responded to a freedom of information request – compared with 181 responses last year – we found six schemes where GPs had a financial incentive to limit referrals, four of which were new.
Four CCGs told Pulse they had schemes offering payment for hitting an outpatient referrals target (see map).
There were also two schemes where savings from reducing secondary care activity were shared with groups of practices.
Both of these were in operation last year. One of them – Coastal West Sussex where 50% of savings are shared with GP federations – says it had allowed more than £1m to be reinvested in primary care services, including extra winter capacity, mental health nurses and social prescribing schemes.
In 2019/20, the focus is set to change from secondary care to making savings from medicines optimisation, such as reviewing drug usage to cut waste.
In Liverpool, there is a quality improvement scheme that has been running since 2011/12 – though it was not flagged to Pulse in our previous investigation – which sees practices ranked by referral data and paid for improvements.
A spokesperson for the CCG said there had been a 7% drop in general and acute referrals since it was introduced – but added that changes in data collection meant it was ‘not possible to confirm how much of this could be directly attributed’ to the scheme.
Liverpool LMC secretary Dr Rob Barnett says the initiative was started to bring extra funding into general practice – and has enabled practices to mitigate workforce pressures seen in the rest of the country. ‘I would not support a scheme if practices were declining to refer people,’ he says. ‘This was about encouraging practices to see what they could do differently.’
CCGs claim these referral schemes are not about cutting referrals per se but reducing unwarranted variation between practices and ensuring referrals are ‘appropriate’.
RCGP chair Professor Helen Stokes-Lampard has hit out at the schemes.
She says: ‘The notion of being incentivised not to refer patients to specialist care when taken at face value will leave a very sour taste in the mouths of GPs, whose primary objective is to act in the best interests of the patient in front of them.’
She added that the suggestion from the CCGs implementing the schemes that ‘GPs will make decisions against their clinical integrity in order to save money is, frankly, insulting and will only erode the great levels of trust our patients have in us’.
Wales, Scotland and Northern Ireland have projects to improve quality, but they have not used the approach of incentivising GPs to hit referral targets.
But in England there are concerns that it will be difficult to eradicate the schemes completely while CCGs continue to claim they produce results.
Former NHS East Surrey CCG chair Dr Joe McGilligan says the schemes will continue until CCGs end their ‘obsession with trying to reduce hospital costs’.
The Redhill GP adds: ‘We need to understand we have an ageing population and it will cost more to care for them – and trying to save money by not doing things doesn’t work – it just kicks problems further down the road.’
But there are signs CCGs are beginning to acknowledge the ethical problems with these schemes. Our investigation this year also revealed more CCGs – 32 – have adopted a ‘peer review’ model of referral management – which involves paying GPs to carry out audit and peer review of referrals as a way to cut variation between practices or individual GPs.
This approach has been called for by the RCGP in the past because it is about quality improvement, paying GPs for their time, but with no arbitrary targets or artificial barriers to referral.
GPs say this development is encouraging, and may reflect a growing appreciation of the profession’s ethical concerns.
Dr Robert Morley, BMA GP Committee policy lead on contracts and regulation, says: ‘I suspect it reflects a realisation by GPs and commissioners of the ethical and professional issues, whether for target-related payments or savings- sharing initiatives.’
Dr Morley adds: ‘CCGs should always be looking to fund schemes to resource time spent on incentivising best practice, rather than targets that perversely incentivise reduced activity or secondary care expenditure.’
Professor Stokes-Lampard also welcomes the reduction in the schemes, saying: ‘It is reassuring to see that the number of CCGs offering an incentive is relatively low and decreasing – and encouraging that many such schemes have been suspended since the college and others spoke out.’
While CCGs seem to be starting to shy away from ‘profit-sharing’, a new iteration of the approach appears to have emerged in the NHS long-term plan, which sets out proposals for primary care networks to take part in a ‘shared savings’ scheme.
Networks – which practices in England are being incentivised to join in the new GP contract – will be able to ‘benefit’ from reducing avoidable A&E attendances, admissions and delayed discharge, streamlining patient pathways to reduce avoidable outpatient visits and overmedication through pharmacist review.
The new contract states that ‘unlike many shared savings schemes’, this arrangement will not ‘create unfunded risk for either CCGs or hospital contracts. Instead, the funding is pre-identified and capped. The exception to this is the prescribing element, which will be funded through the existing primary care drugs budget’.
However, NHS England is unable to provide any further details.
Family Doctor Association chair Dr Peter Swinyard says that if there was no direct payment and the scheme enabled surplus funding to be moved to primary care, this could be of benefit.
‘If there were fewer referrals, attendances or admissions, there would be money left in the total budget,’ he says.
Dr Dean Eggitt, Doncaster LMC chief executive officer, says: ‘Assuming any resource is reinvested in care, I have no concern.’
However, he adds: ‘Any scheme that gives a clinician money in their pocket to keep a patient away from medical help is perverse and deserves condemnation.’