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GPs still incentivised to cut referrals but scheme numbers decline

The number of schemes offering financial incentives for GPs in return for cutting referrals has declined over the past year, according to a Pulse investigation.

Pulse’s ‘Cash for Cuts’ investigation in 2018 identified 11 CCGs offering financial incentives to cut the number of referrals they made to secondary care, including five areas where they received a cut of the savings made from the reduced activity. 

But only six of the 174 CCGs who responded to an FOI this year said they offered incentives for GPs to hit a target for cutting referrals, including two that had ‘shared savings’ schemes in place where groups of GP practices received a proportion of the money saved from hospital appointments.

RCGP chair Professor Helen Stokes-Lampard, said it was ‘reassuring’ to see that the number of CCGs offering some kind of incentive is relatively low and encouraging that many such schemes have been suspended.

Last year’s investigation prompted widespread condemnation, including from the BMA and RCGP, and led to the issue being raised in Parliament by the shadow health secretary.

The new figures suggest CCGs are shying away from offering cash to GPs to help reduce secondary care activity and balance the books.

Many of the schemes with specific targets for reducing referrals no longer exist – including an ambitious target in Barnsley to cut referrals across a range of specialties – according to responses from CCGs.

But the new investigation found schemes in Rushcliffe, Bolton, Bassletlaw and Liverpool where a payment is still linked to a reduction in referrals.

An agreement to share 50% of savings from elective activity with GP federations is also still in place in Coastal West Sussex, whereby they can reinvest in patient services. However, the CCG said from 2019 the focus will shift to ‘medicines optimisation’.

A profit-sharing scheme also remains in West Leicestershire, although it has shifted from reductions in elective referrals to secondary care activity overall.

The responses showed more CCGs have adopted a peer review approach, paying practices to scrutinise appropriateness of referrals.

CCGs with incentive schemes said the goal was to reduce ‘unwarranted variation’ in referral rates between practices.

Professor Stokes-Lampard, said: ‘CCGs are under considerable pressure to make efficiency savings, but it’s important that they trust GPs to use our skill and expertise to refer on the basis of clinical need and only if we think it is in the best interests of our patients.

‘To this end, we are pleased to see many CCGs move towards a peer-review model of referral management, which the College advocated in our review of referral management centres last year.’

Dr Dean Eggitt, chief executive of Doncaster LMC, said there had been ‘universal condemnation’ of schemes which offered payment to hit a reduced referral target.

But he stressed he did not have concern with schemes where savings were reinvested in patient care.

‘I support funding of practices enough so that they do not have to worry about taking on immoral schemes just to keep the lights and heating on,’ said Dr Eggitt.

Dr Rob Barnett, secretary of Liverpool LMC, said the scheme in Liverpool was about best practice and had enabled practices to mitigate workforce pressures.

‘I would not support a scheme if practices were declining to refer people,’ he said. ‘This was about encouraging practices to talk to their neighbouring practices to see what you could do differently.’