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GPs to be asked to ‘peer review’ all referrals

Exclusive CCGs are formulating plans to scrutinise practices’ referral systems after a leaked NHS England memo showed they have promised to incentivise peer review schemes in order to reduce referrals by 30%, Pulse has learnt.

Pulse has learnt that NHS England wrote to CCGs in May, asking them to ensure that there is ‘clinical peer review of all referrals from general practice by September 2017’, and this should be done on a weekly basis.

The May 2017 guidance ‘Elective Care High Impact Interventions: Clinical Peer Review’ says that there will be ‘significant additional funding’ for commissioners to establish GP peer review schemes this year.

Pulse has seen an email from NHS Bedfordshire CCG to commissioners on plans to scrutinise GPs’ referral schemes.

It states: ‘As you will be aware there is now an ask from NHS England for us to ensure we have 100% coverage of prospective peer review in practices. The attached document sets this out. [The local area team] needs assurance from that we have a plan to do this and how that will be rolled out across practices.’

The email includes an attachment from NHS England on plans to incentivise these peer review schemes.

The NHS England report says: ‘Significant additional funding is being given to regional teams in 2017/18 to roll out and spread interventions and schemes that will help CCGs to deliver a slower growth in referrals.’

It states that good practice would be for GPs to review each other’s new referrals, at least once a week, to ensure that ‘all options are explored and that patients are seen and treated in the right place, at the right time and as quickly as possible.’

But the guidance also makes clear that that the process ‘should not be established as an approval process’ and the ‘referring GP retains responsibility for the patient and makes the final decision’

This comes after Pulse recently reported on a pilot scheme in the North East of England, under which GPs must get approval for routine referrals from a team of GPs and GPSIs.

NHS England claim that ‘published literature identifies internal peer review as a positive intervention with benefits to patients and GPs and it could also reduce referral rates by up to 30%’.

But Professor Azeem Majeed, professor of primary care and head of the department of primary care and public health at Imperial College London, warned that referral management schemes can sometimes ‘result in delays in referrals’, particularly when assessors are ‘not fully aware of the background to the referral’.

He said: ‘To carry out effectively, clinical peer review requires adequate time and resources.

‘Given the current pressures on NHS general practice in England, this scheme may well end up as a tick-box exercise rather than something that will improve patient outcomes and NHS efficiency.’

GPC clinical lead Dr Andrew Green said: ‘I wish NHS England put a tenth of the effort they expend on reducing pressure on hospitals into reducing pressure on GPs, which is the area of the health service with the biggest growth in workload.

‘We are used to seeing un-referenced claims such as “could reduce by up to” in adverts for antiwrinkle cream and I am surprised to see such language in an official document.

‘It is important to be aware of the lost-opportunity costs of schemes like this, if we assume an hourly weekly meeting that would be equivalent to removing 1000 GPs from the English workforce, GPs we don’t have.’

An NHS England spokesperson said: “Clinical peer reviews are a simple way for GPs to support each other and help patients get the best care, from the right person, at the right time without having to make unnecessary trips to hospital. More than half of CCGs have already implemented some of peer review system, with Luton seeing an 8% drop in hospital referrals, and the latest NHS England guidance will help ensure best practice is shared to remaining local commissioners.”

A spokesperson at NHS Bedfordshire CCG said: ‘The executive team at NHS Bedfordshire CCG is currently in discussion with clinical leads on the implementation of the Clinical Peer Review system.

‘Details of the agreed system will be advised in due course.’