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GPs left to manage third of urology referrals under CCG cost-cutting drive

Exclusive A new scheme in the South West of England designed to streamline primary care referrals to urology specialists has seen nearly a third of referrals sent back to GPs to manage, leading to fears around patient safety and workload. 

The scheme at NHS Northern Eastern and Western Devon CCG has required GPs to carry out further investigations usually done by the specialist, and in some cases tests they were not equipped to do.

The CCG said that it was satisfied an initial six-week pilot of the scheme showed it was safe to be rolled out more widely – with the prospect of expanding the approach to other specialties.

But Devon LMC leaders said they are concerned the pilot was not properly evaluated and the scheme is putting cost-cutting above patient safety – with no extra resources available to GPs to carry out the work. 

Under the scheme, consultants from another area – Gloucestershire – carry out an initial review of all GP urology referrals, to judge whether the patient should be booked in for a specialist outpatient appointment, or should be sent back to the GP with a management plan and recommendations to order tests directly.

The CCG said that sending patients back to GPs with a management plan speeds up the process for patients, as they do not have to wait weeks for a face-to-face appointment with a specialist.

But Dr Mark Sanford-Wood, from Devon LMC executive, told Pulse the LMC was concerned the CCG’s evaluation ‘related almost entirely to cost reduction, and appeared not to give sufficient consideration to safety and quality or to increased GP workload’.

Figures given to Pulse by the CCG show that during the first six weeks, 141 (30%) of all referrals were sent back to the GP with a management plan, with the majority of those requiring the GP to do a trial of therapy or investigations, including pre- and post-voiding ultrasounds and CT scans.

A total of 15 patients had to be re-referred, and the CCG said further evaluation is underway to find out whether this related to GPs not being able to carry out the requests, and whether it had delayed any diagnoses or treatment.

However, it said that after reviewing the six-week pilot it had ‘instructed those undertaking the referral review not to return those kinds of investigations for primary care… for the time being’. 

The CCG announced over the summer that it was rolling out the scheme to the rest of the region, to evaluate if the approach is of benefit and ‘whether this should be expanded to other specialties’. 

Dr Sandford-Wood said that the LMC was aware that GPs were still being sent back referrals with orders to arrange tests that were not available to them because of local protocols, and that GPs were too busy to carry out all the follow-up appointments with no extra resources.

He said: ‘The overall drive is to move the first and even in some cases the second outpatient appointment into general practice. For each of those outpatient attendances saved they could use the money to reinvest in general practice to do the work, and they aren’t doing that – it is, first and foremost, a cost-saving measure.’

Dr Sandford-Wood said the prospect the scheme could be expanded to other specialties was a ‘massive concern’.

He said: ‘Having done this in urology they may decide there are many other specialties where they could do this, thereby significantly cutting their outpatient referrals and costs. That is of massive concern to the LMC, primarily because it would crush practices and destabilise core general practice services.’

NEW Devon CCG said in a statement it was ‘aware of the concerns’ from Devon LMC but that these highlighted ‘potential outcomes of such a service rather than what has actually taken place’.

It comes as Pulse reported earlier this month that NHS St Helens CCG was forced to back down from cost-cutting proposals to ban all non-urgent referrals during the winter.


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