Exclusive GP practices in five areas of the country are being offered controversial ‘profit share’ agreements that see them paid up to half the savings if they refrain from referring their patients to hospital.
The controversial payments – up to 50% in some cases – are revealed as part of a major Pulse ‘Cash for Cuts’ investigation looking at how local health organisations are taking the pressure off secondary care.
But the payments have been called a ‘dereliction of duty’ by GP leaders, who argue that cash incentives should have no place in the consulting room. And they come after the RCGP raised concerns about the effect of referral restrictions on patient care.
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Pulse revealed one profit-sharing scheme last year for reducing prescribing in care homes, but this is the first report of similarly designed to reduce non-urgent GP referrals. Pulse’s ‘Cash for Cuts’ investigation received freedom of information responses from 181 CCGs, with a quarter offering some kind of financial incentive designed to cut referrals to specialists.
Eleven of these were offering a direct incentive based on GPs changing their referral behaviour, with five ‘profit sharing’ schemes, including:
- NHS Coastal West Sussex CCG told Pulse it is offering groups of GP practices 50% of the savings on any reduction in elective activity from the previous year
- In West Leicestershire, GP federations receive 30% of savings made on first elective referrals
- NHS Vale of York CCG offers GP practices a ‘gain/share’ arrangement for dermatology referrals and ‘a proportion of any savings achieved’
- NHS Enfield CCG in north London says 50% of any cost reduction for GP-referred outpatient attendance ‘will be shared with the locality’
- NHS Wolverhampton CCG says it is considering a profit-sharing scheme.
The CCGs say that the funding is to be used on patient care, and that the schemes have been implemented to improve the quality of referrals (click here for their full responses).
Other areas were offering payments for big reductions in elective referrals, including a £1.4m scheme that sees practices paid £5 per patient for cutting GP referrals by at least 10% – described as ‘unsafe and needs urgent review’ by the local BMA GP representative – and one including cancer referrals.
Dr Peter Swinyard, chair of the Family Doctor Association said the profit-share schemes were ‘bizarre’, adding: ‘From a patient perspective, it means GPs are paid to not look after them. It’s a serious dereliction of duty, influenced by CCGs trying to balance their books.’
Former RCGP chair and south London GP Professor Clare Gerada said: ‘We should be concerned about any incentive to alter behaviour that is not in patients’ best interests.’
Referral incentive schemes have proved controversial in the past, with Pulse reporting plans for GPs to peer review all referrals and NHS England scolding CCGs for offering incentives to GPs for cutting down the number of urgent cancer referrals they make.
The BMA’s GP Committee chair Dr Richard Vautrey said: ‘We’ve raised concerns about these schemes where there is an arbitrary target.’
GPC clinical and prescribing lead Dr Andrew Green said: ‘This idea is the unflushable stool in the toilet of desperate measures.’
Dr Amanda Doyle, co-chair of NHS Clinical Commissioners and chief clinical officer of NHS Blackpool CCG, said: ‘Any initiative or scheme that aims to manage referrals from primary care to secondary care must of course put patients, not finances, at the heart of decisions and should be about making sure referrals are appropriate and not just about reducing the number.
‘Directly linking payments to reductions is not appropriate and NHS England, as the regulator, would take a role in addressing that circumstance.’
Dr Jeremy Mayhew, clinical lead for primary care at NHS Coastal West Sussex CCG, said: ’The agreement focuses on reducing the number of inappropriate or incomplete referrals, when a patient can be waiting several months only to be bounced back to their GP practice – causing a delay in care for that patient and a cost to the NHS system.
’To encourage GP practices to take the time to review their referrals and share this learning, GP practices are able to access half of the money that is saved within the NHS system by reducing these inappropriate referrals.
’After approval by the CCG, this money is then spent on improving access to their services for local people and the development of local community services; no GPs receive payment, directly or indirectly.’
For a full list of CCG responses, please click here
More on Pulse’s ‘Cash for cuts’ investigation
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