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Commissioning dilemma: LES for more cost-effective referrals

Your consortium has agreed a LES which contains a component for paying for making your referrals more cost-effective, but you are concerned that this is code for reducing your number of referrals. Should you agree to it? Dr Helena McKeown advises.

I know that I would be in breach of my duties to the patient in front of me if I were to receive a direct financial payment to not refer that patient if that was the right clinical decision[1]. However, I am aware from benchmarking my behaviour that we all vary significantly in at least some of our referral and admission rates and that many of us are interested in how our practice compares to other GP colleagues. Reviewing either the most expensive referrals or those where as a GP or practice we are an outlier is a useful way to both educate us as GPs and consider alternatives that may be better for an individual patient. So what is the LES I'm being asked to agree to actually saying?

Does it ask me to take part in referral analysis or does it ask me to reduce referrals by x, full stop, and reward me for achieving a target reduction? The former is acceptable, the latter is not.[2]

Does the LES resource this process of peer discussion facilitating new ways to manage patients, as a practice "in-house" or group of practices? Does the LES support me seeking advice from consultants in management (a service which could be commissioned by the GPCC)?. These would be appropriate reasons to agree to the LES.

Some referrals and admissions could safely be avoided if alternatives were in place in the community; have the GPCC commissioned such care closer to the patient? If they have, then I am content that by signing the LES I am making the pathway both better for my individual patient and making more efficient use of NHS resources.

Does the LES place undue pressure on colleagues to alter how they care for their patients? Reducing referrals without exploring or promoting clinically appropriate alternative pathways of care which are acceptable to the patient is not acceptable.

Dr Helena McKeown is a member of the GPC Commissioing and Service Development Sub-committee, and GPC member for Wilts and Dorset.

Dr Helena McKeown