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Commissioning dilemma – delaying hospital treatment

Your practice has had an unexpectedly high referral rate in the last quarter, and you are worried you are likely to come under scrutiny. A patient consults you who needs hospital treatment, but they could wait a couple of months until the next financial year. Should you delay their treatment? Dr Shane Gordon tackles this dilemma

NHS budgets need to balance year on year, not an ideal situation when there is year on year variation in demand levels within a relatively small population like an individual practice. However, you are likely to be under a contractual obligation to keep within budget, from April 2013. Previously it was acceptable practice to delay elective referrals or procedures to push that cost into a subsequent year. However, the NHS constitution (now enshrined in law) gives patients the right to elective treatments within 18 weeks of referral. This means that you can only control when you refer, not when the patient gets treated in hospital. This is not about denying patients essential treatment but often comes down to your personal thresholds for referral. There is often a difference between GPs in their confidence to manage particular problems, even within the same surgery.

Common examples of variation in threshold might include at what stage to refer a patient with knee pain. In this circumstance the first question I would ask myself, or a colleague, are there any alternative treatments or different ways of managing the problem? Have all conservative management options been considered? Has the patient considered the risks as well as benefits of possible treatment? Bear in mind the first year of Patient Reported Outcome Measures data which show that nearly 50% of patients don’t perceive an overall quality of life improvement after knee replacement. Consider discussing the case with a specialist before referral; many areas have set up email or telephone systems to allow this. In NHS East of England we are piloting a system called NHS Confer which allows GPs and Specialists to share instant messaging, email, phone and screen capture.

Referring might seem like an easy option but you will need to maximise the use of all the other options available to your patients in order to deliver good care within budget.

Dr Shane Gordon is GP Commissioning Lead for NHS East of England, national Co-Lead of the NHS Alliance’s GP Commissioning Federation, and chief executive of the North East Essex GP Commissioning Group

Dr Shane Gordon