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CCGs start to tighten screw on GP referrals

Exclusive GPs in one clinical commissioning group (CCG) are being told to limit their referrals to as few as four a week amid concerns pressure to reduce hospital use is seeing some GP commissioners resort to unacceptable ‘micromanagement' of practices.

One of the country's leading GP commissioners warned there was a danger of general practice becoming a case of ‘them and us' after a Pulse investigation found a series of controversial referral restrictions by CCGs.

A second CCG is restricting GPs' physiotherapy referrals, a third is embroiled in a row over limits on surgery for smokers and the obese, while another is implementing a balanced scorecard benchmarking referrals.

The restrictions emerged a week after GPC chair Dr Laurence Buckman warned some CCGs were implementing ‘untried and unacceptable measures to micromanage practices'.

In east London, Redbridge CCG has used PCT calculations to allocate practices an annual budget for first referrals, which practices have used to work out referral limits for each GP – in some cases an average of just four a week.

Dr Sarah Heyes, CCG clinical director and a GP in Wanstead, said: ‘Each practice has been allocated a fixed amount of money from which the price of a first referral is averaged out. Obviously cardiology is much more expensive than, say, dermatology, but we average it and then work out the number of referrals allowed per year per GP.

‘In our practice's case, it came up with the figure that I was allowed four referrals a week. To be honest, I had sleepless nights and was quite panicked, thinking it would restrict my practice as a GP.'

Dr Heyes said the target had not stopped her making necessary referrals and had made her ‘more aware of the numbers', while an NHS Redbridge spokesperson said the targets were ‘not a directive' and referring patients was always GPs' ‘clinical decision'.

But Dr Richard Vautrey, GPC deputy chair, said: ‘This type of simplistic idea of setting quotas at practice level is potentially very dangerous.

‘Every practice sees week-by-week variation in referrals, and to place limits on referrals in this way risks patients who really do need specialist care not being referred when they need to be, or at all.'

Meanwhile in Nottingham, Principia CCG has told GPs to refer to a physiotherapist only if patients have presented twice for the same condition at least six weeks apart. Nottinghamshire LMC chair Dr Greg Place said the restrictions, which also limit GPs to one physiotherapist referral a year per patient for each condition, had left him ‘narked': ‘I don't mind them giving me guidance but I do mind them telling me what to do, as is happening in this case.'

A Principia spokesperson said the restrictions had drawn no complaints from patients and were in accordance with national guidelines.

Elsewhere, East London City Alliance CCG in Tower Hamlets has rejected crude numerical limits to referrals, but is sending a balanced scorecard to GPs each week and is working on benchmarking referrals by clinical area. And in Hertfordshire, GPs warned CCG-backed restrictions on surgery for smokers and the obese had been implemented ‘shambolically'.

Dr Michael Dixon, NHS Alliance chair, said CCGs faced a ‘difficult task' in redesigning services cost-effectively: ‘This may bring them into conflict with GPs, but I'd be concerned if CCGs become regarded by GPs as "them" rather than "us".'

Dr David Stout, a director of the NHS Confederation, said these kind of protocols would become more common, with possible sanctions for those not complying.

‘It would all depend on the constitution of the CCG and what behaviour is expected by practises and then what measures are sanctioned for not fulfilling that. I suppose if a constitution allowed it a practice could be kicked out but that would be a pretty blunt instrument and would certainly be the nuclear option.'