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GP practices offered payments to cut urgent cancer referrals

Exclusive GP practices are being offered thousands of pounds to refer fewer patients for specialist care, including those with suspected cancer, finds a Pulse investigation.

Pulse has learnt that in at least nine CCGs, practices are being offered payment for keeping within targets for outpatient referrals and follow-ups. And some of these schemes even count two-week cancer wait referrals towards the target.

The GPC says many of these schemes could be ‘ethically questionable’ and Pulse has learned that the GMC looked into at least one of them to see if it is contrary to the guidance for doctors in Good Medical Practice.

The investigation comes as the health service prepares to implement £22bn of efficiency savings by 2020, and shows that restrictions are increasing on routine, front-line care. Examples of the schemes that are being run across the country are:

  • NHS North-East Lincolnshire CCG is offering payments that would equate to more than £6k for the average practice to reduce outpatient referrals to the same level as the 25% of practices with the lowest referral rates – including two-week urgent cancer referrals – in 2014/15.
  • NHS Birmingham South Central CCG is offering the average practice a payment that would equate to in excess of £11k to reduce new outpatient attendances, follow-ups, A&E attendances and emergency admissions by 1%, compared with 2014/15. The CCG says it has considered the ‘full impact’ of the incentive scheme and is ‘confident that there is no conflict of interest’.
  • NHS Lambeth CCG is offering payments for practices moving towards the average 2014/15 CCG referral rate per 1,000 patients. The CCG claims that urgent care and two-week cancer referrals ‘cannot be separated’ from the overall numbers.

Dr Robert Morley, chair of the GPC’s contracts and regulations subcommittee, told Pulse that schemes incentivising practices to reduce urgent cancer referrals were ‘extremely concerning’.

He added: ‘These may, at face value, potentially be ethically questionable and conflict with GMC guidance, on the basis that they might conceivably influence individual management decisions.’

Former RCGP chair and Lambeth GP Professor Clare Gerada told Pulse she believes such schemes risk ‘interfering with the doctor-patient relationship.’ She says: ‘Once we start incentivising to reduce activity, then it puts a conflict within the consulting room.’

Pulse has learnt that one scheme has already been looked at by the GMC, after being referred by local GP leaders.

Dr George Ogden, chair of Bolton LMC, told Pulse that the LMC fears that NHS Bolton CCG’s ‘quality contract’, which pays practices for reducing referrals for procedures of ‘limited clinical value’ by 20% – such as vasectomies – and for reducing first outpatient appointments and follow-ups by 1%, could fall foul of the GMC’s guidance.

Dr Ogden said: ‘The GMC said it would potentially be regarded as an inducement if there was a challenge that GP behaviour changed as a result of the payment. So they were concerned, but didn’t say it was entirely against the guidance.’