Exclusive Several schemes that incentivise GPs to cut the number of referrals through ‘profit-sharing’ agreements remain in place, despite an outcry when they were first highlighted by Pulse.
A ‘Cash for Cuts’ investigation published in February identified new ways in which CCGs are trying to take pressure off secondary care.
Of the five profit-sharing schemes in which GPs receive a proportion of savings to reinvest in general practice, three have been taken forward to the 2018/19 financial year, and one is under review.
NHS Wolverhampton CCG, who were considering putting in place a profit-sharing scheme to cut referrals, decided not to go ahead and NHS Enfield CCG said it had not finalised its plans.
NHS Vale of York CCG, who offered GP practices a ‘gain/share’ arrangement for dermatology referrals and ‘a proportion of any savings achieved’, confirmed the scheme remained in place but stressed that any saving was invested back into ‘improving patient services’.
The CCGs highlighted in Pulse’s investigation – which was raised in Parliament – say the schemes are intended to reduce ‘inappropriate referrals’.
A statement from NHS Coastal West Sussex CCG said their scheme, which offered groups of GP practices 50% of the savings on any reduction in elective activity from the previous year, remained in place for 2018/19 ‘after demonstrating a reduction in inappropriate and incorrect referrals’
But it said: ‘Practices are not individually incentivised for a reduction in referrals; any efficiencies made by the appropriate referrals being made are funding new services in primary and community care.’
NHS England figures show that GP referral rates to hospitals for elective care have fallen by nearly 2% in the last year.
Board papers which show elective GP referrals have fallen by 1.6% between 2016/17 and 2017/18, compared to an average annual growth of 3.8% in the previous four years, praised CCGs for curbing referral rates.
The news comes as the BMA has published a briefing on referral management schemes, which recommends that CCGs ‘undertake formal evaluations of all referral management schemes in operation. It also says NHS England and the UK Government ‘must clarify that the clinical responsibility will rest with the individual making the decision that a referral will or will not proceed’.
Earlier this year, the RCGP called for referral management centres – another approach CCGs have taken to reduce referrals – to be scrapped over a lack of evidence they were ‘cost effective or safe’.
BMA GP Committee prescribing lead Dr Andrew Green said: ‘Where CCGs wish GPs to take on extra work in order to improve patient care by refining referral pathways then we would approve of, indeed we would expect, GPs to be paid for that activity.
‘What must not happen is for any payment to be dependent on reductions in referrals, as that would create a conflict of interest which would be unethical and may undermine the doctor/patient relationship.’
Dr Peter Swinyard, chair of the Family Doctors Association, said peer review, audit, and education were all appropriate ways to review referral practices but that it was ‘extraordinary’ these schemes were still in place.
‘We mustn’t put these barriers up, we must make it so doctors can refer people they feel need it and not patients worry we are making decisions for purely financial reasons or practice financial benefit.’
CCG responses in full
NHS Enfield CCG
‘I can confirm that NHS Enfield CCG has not finalised our Locality Commissioning Plan for this financial year as yet, as we are reviewing it in light of our Care Closer to Home priorities in Enfield.’
NHS Vale of York CCG
‘To improve service quality, safety and patients’ experience of care Dermatology Indicative Budgets remain in place during 2018-19. All treatment that is provided within the community and every decision to refer to secondary care are based on clinical evidence. Any saving made by providing clinically appropriate treatment or referrals is invested back in to improving services and patient experience.’
NHS Barnsley CCG
‘The assessment process for onward referral for treatments based on clinical evidence is still in place. The investment for 18/19 has reduced to reflect the changes in referral culture to reduce inappropriate referrals which took place in 17/18. The 18/19 scheme supports ongoing activities e.g. training activity, peer review, use of advice and guidance services etc.’
NHS Rotherham CCG
‘Despite previously published information, NHS Rotherham CCG has never incentivised GPs out of ‘savings’ from reduced referrals to secondary care. We do not want to reduce the number of patients being referred to hospital where they need further treatment or investigation, especially those with cancer symptoms.
‘Our aim is and has always been to encourage best practice that prevents inappropriate referrals that have no benefit to the patient, not stop those who need further treatment from being referred to hospital. We want to reduce clinical variation and ensure secondary care capacity is appropriately utilised as inappropriate referrals can lead to delays in appropriate care and treatment.’
NHS Coastal West Sussex CCG
‘Yes, the CCG’s GP Transformation Agreement is in place for 2018-19 after demonstrating a reduction in inappropriate and incorrect referrals, making care more efficient for patients, and improving medicine management reviews. It is important to be clear it is not a referral incentive scheme, and practices are not individually incentivised for a reduction in referrals; any efficiencies made by the appropriate referrals being made are funding new services in primary and community care.’
NHS Wolverhampton CCG
‘Wolverhampton CCG did consider the approach in 2017, however it was not taken forward in either last financial year and will not be done in this financial year either.’
NHS West Leicestershire CCG
‘In 2018/19, we are again encouraging federations to look at reducing unwarranted variation and improve the quality of referrals within their area. The initiative forms part of an overall quality improvement approach that aims to support working at scale, support the sustainability of general practice and address unwarranted variation.
‘The scheme includes a number of initiatives to support the delivery of high quality care including advice and guidance services, peer review and education. It is also linked to system-wide initiatives to improve patient pathways across planned and urgent care.
‘Through the work done in this scheme to improve the appropriateness and timeliness of referrals, identify and spread best practice and efficiency, and to refer patients to the ‘right place’, we will improve the experience of, and the outcome for, the patient.’