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Dereliction of duty? GPs offered cash to reduce referrals

cash for cutslogo 580px387px

cash for cutslogo 580px387px

‘It’s bizarre that CCGs think they can get away with it.’

This view from Family Doctor Association chair Dr Peter Swinyard is shared by many other GPs, appalled by the development of new ‘profit share’ schemes that incentivise practices to drive down their referral rates.

‘From a patient perspective, it means GPs are paid to not look after them. It’s a serious dereliction of duty, influenced by CCGs trying to balance their books,’ Dr Swinyard adds.

‘The scheme is unsafe and needs to be reviewed urgently’

Dr Dean Eggitt

A Pulse investigation into the introduction of new curbs on GP referrals shows nearly a quarter of CCGs have implemented some kind of cash incentive scheme to cut GP referrals. The majority of these involve the introduction of new processes, such as peer review. But at least 11 are, more controversially, attaching GP funding to overt targets, meaning GPs are actively incentivised to refrain from referring.

And five CCGs have, or are planning, some kind of ‘profit-share’ component for GP practices – effectively meaning GPs get paid extra every time they decide not to refer a patient – a new type of scheme that some regard as completely unethical.

This is despite a fall in GP referral rates last year. In 2017, GP referrals decreased by around 0.5% compared with the previous year, while referrals from elsewhere increased.

NHS England chief executive Simon Stevens even congratulated GPs for this, telling delegates at the NHS Providers conference late last year that ‘GPs have taken unprecedented action to manage elective demand’.

outpatient sign square PPL Debate

outpatient sign square PPL Debate

outpatient sign square PPL Debate

Read all about our ‘Cash for cuts’ investigation

But the national focus on relieving pressure on hospitals continues. Last year, NHS England tasked CCGs with achieving a ‘slower growth in referrals’, saying rising demand for elective services was ‘leading to an increasing national waiting list [and] longer waiting times’ and figures from December shows waiting times at their highest since September 2008.

As a result, CCGs are continuing to focus on GP referrals – and there are major concerns about their methods.

NHS Coastal West Sussex CCG tells Pulse it is offering groups of GP practices 50% of the savings on any reduction in elective activity from the previous year, excluding urgent cancer referrals.

Similarly, in West Leicestershire, GP federations receive 30% of savings made on first elective referrals, while NHS Vale of York CCG offers GP practices a ‘gain/share’ arrangement for dermatology referrals and ‘a proportion of any savings achieved’.

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referrals p15%20 mar%202018 580px

NHS Enfield CCG in north London says 50% of any cost reduction for GP-referred outpatient attendance ‘will be shared with the locality’, while NHS Wolverhampton CCG also says it is considering a profit-sharing scheme.

A similar scheme, this time for prescribing, was uncovered by Pulse last year. NHS Oxfordshire CCG said it was asking practices to review 10% of care home patients and offering them the opportunity to keep half the cash from any savings in the prescribing budget. This was so controversial that it made the front pages of national newspapers last year, with the BMA’s GP Committee suggesting the CCG was prioritising savings over patient care.

Where is the evidence?

There has been little research on whether GP cash incentives to cut referrals actually work, as they are a relatively new concept. However, The King’s Fund did warn in 2010: ‘The use of financial incentives can be effective, but if used to drive blanket reductions in referral rates there are risks that necessary as well as unnecessary referrals will be reduced.’

Much more has been written on referral-management systems in general. An audit in 2014 by a north-west London trust’s rheumatology department, published in Rheumatology, found that referral management systems hold up urgent referrals and prevent patients undergoing investigations within recommended time limits.

Meanwhile, a three-year study, from April 2009 to March 2012 and published in the BJGP in 2013, showed referral management services – such as referral management centres and internal peer review of referrals – failed to reduce outpatient attendance rates and, in one case, actually increased rates.

Now, the RCGP has launched a review of the schemes. Chair Professor Helen Stokes-Lampard told Pulse: ‘We are concerned that some referral management centres focus on reducing the number of referrals when there is insufficient evidence to show this is cost effective or better for patients.’

Now this approach has been extended into GP referrals. CCGs claim their sole intention is to improve the quality of referrals, and all ringfence the money, obliging GPs to spend it on patient care. But GPs say this is irrelevant, as the rules are so loose in this area and patients will see their GP gain a bonus from not giving them the best treatment – potentially damaging trust and delaying their care.

Other areas have introduced brutal targets for GP elective referrals, where GPs receive a set amount, rather than a share of profits; these have been called ‘unsafe’ by local GP leaders.

NHS Barnsley CCG tells Pulse it has introduced an ‘achievable’ target to cut 10% of elective referrals across a range of specialties, including cardiology, gastroenterology and orthopaedics.

’We should be concerned about any incentive to alter behaviour that is not in patients’ best interests’

Professor Clare Gerada

Dr Dean Eggitt, who is the GPC representative for Barnsley, Doncaster, Rotherham and Sheffield, is forthright in his criticism of the initiative in his area: ‘The scheme is unsafe and needs to be reviewed urgently.’

Barnsley is not alone. NHS Rotherham CCG has implemented an incentive for practices for practices to reduce first outpatient appointments and follow-up appointments by 1%, or down to the ‘cluster average’, as part of a wider scheme worth £3.36 per patient. The CCG says the scheme covers all referrals, including those for cancer, despite a national outcry when Pulse reported the introduction of similar schemes in 2015. 

Former RCGP chair and south London GP Professor Clare Gerada said: ’We should be concerned about any incentive to alter behaviour that is not in patients’ best interests.’

The BMA is heeding GPs’ concerns, Pulse has learned. GPC chair Dr Richard Vautrey says: ‘We’ve raised concerns about these schemes where there is an arbitrary target.’

But as the NHS struggles to balance its books, these types of bonus schemes seem to be becoming more complex and more prevalent.