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CCGs applying ‘arbitrary’ criteria to limit GP referrals, royal college finds

Almost half of CCGs are using ‘abitrary’ criteria for referrals that lack clinical evidence, leaving GPs ‘frustrated’, the Royal College of Surgeons has found.

The Is access to surgery a postcode lottery report by the RCS identified that 44% of 53 CCGs used ‘arbitrary’ criteria that did not comply with NICE guidelines to set an appropriate referral.

The report identifies that the criteria employed included patients being in a certain amount of pain or disability – but without a universally applied standard – before they can be considered for procedures like hip replacements.

It recommends that the Government and NHS England ‘review what further action is required to ensure the NHS is providing equitable access to high-quality surgical care’ and CCGs ‘urgently need to ensure their commissioning policies are in line with the clinical evidence base’.

The royal college suggests that ‘financial’ considerations are a factor in determining policy, but CCG leaders have rejected the suggestion and say policy considers evidence and the needs of local populations.

The report’s key findings state:  ‘We are alarmed that 44% require patients to be in various degrees of pain and immobility (with no consistency applied across the country) or to lose weight before surgery. This is considered to be unacceptable by NICE, the RCS and the British Orthopaedic Association (BOA).’

It adds: ‘While it is impossible to prove categorically that CCGs are imposing arbitrary criteria for financial reasons alone, some CCGs’ policies do not reflect clinically accepted evidence-based guidance so we question how these policies were conceived.’

‘Our primary concern is that there is no clinical justification for many of the policies discussed in this report.’

But Dr Steve Kell, co-chair of NHS Clinical Commissioners leadership group and chair of Bassetlaw CCG said: ‘CCGs are clinically led organisations that make clinically led decisions centred on the needs of their patients and local populations and to insinuate that their motivation is purely financial is wrong.’

‘There must be a balance between local decision making and national guidelines and NHSCC will be working with NICE and others to make sure that happens.’

But GPC deputy chair Dr Richard Vautrey told Pulse that doctors and patients struggled to understand the regional differences in referral policy, and said it was a ‘reality’ that CCGs would have to ‘balance the books’.

Dr Vautrey told Pulse: ‘GPs are frustrated that there remain many of the barriers in place which prevent them making the referrals that they believe to be necessary that there always had been with PCTs.’

‘The reality is that whoever is making the commissioning decisions, responsible bodies are expected to balance the books first and foremost.’

‘However, GPs and patients find it hard to understand why one area is able to directly access a specialist when necessary whilst others are unable to do so.’

Pulse recently revealed how area teams were rewriting enhanced service specifications to limit the amount of minor surgery GPs were performing.