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Dilemma: Incentive scheme to reduce referrals

Dr Tony Grewal: Such schemes mustn’t be imposed on practices

Dr Tony Grewal

It is important to understand that CCG governing bodies are supposed to represent and implement the views of their member practices in their commissioning activity and should not be imposing externally driven initiatives without appropriate consultation with and involvement of their membership.

Current guidance is that no new local enhanced services should be offered this year and that local community service contracts should be subject to current competition guidance.  If this is an incentive scheme, then the only contractual basis for its funding lies under section 96 of the NHS Act 2006. Any such schemes are voluntary – they cannot be imposed on practices.

It may be necessary to remind a CCG governing body of these principles. A practice might then ask their CCG governing body to explain the basis for looking to reduce ophthalmology referrals. What are the current referral rates? How do they compare with referral rates in other CCG areas with similar demography?

If there is a higher referral rate, is this across all practices, or is there unexpected variation between practices? Is there evidence of significant numbers of referrals for procedures without evidence of benefit? What alternative pathways exist to refer for a diagnostic opinion or patient reassurance? Are local opticians (who generate GOS1 referral requests) signed up to this initiative?

Practices may well seek the support of their local medical committee in ensuring that such an initiative is evidence based and that patient concerns (or complaints) can be addressed without the implication that GPs are making money by refusing to refer for necessary treatment.

Dr Tony Grewal is a sessional GP in Hillingdon and medical director of Londonwide LMCs.

Dr Amit Bhargava: Seek assurances from the CCG clinical lead

Dr Amit Bhargava Charles Milligan

As a jobbing GP in a CCG member practice, when faced with the dilemma of incentives for reducing ophthalmology referrals, I need to be assuredof a number of things.

I would initially talk to our practice GPs and practice representative on the CCG. But if not convinced, I would contact the lead CCG clinician for planned care and copy in the clinical lead for the CCG, to ask the following questions:
- Why do we need to reduce referrals and by how much?
- What are the conditions that we are referring too much of?
- Are there guidelines and referral pathways that need to be followed or changed?
- What is the evidence base and who has approved this?
- Have the patient group been involved in the decision?
- Has the CCG produced any patient information guidance?
- Is there a training course on ophthalmology that needs to be attended before joining the scheme?
- Has an ‘ethics committee’ approved this scheme?
- What can I use the incentives money on?

Once I have had a satisfactory answer to these questions - they may well be in the original approved business case - I would be happy to go ahead and do my best to make the scheme a success. The caveats would remain that any management plan must be in the best interests of the patient, have their full knowledge and consent and I should be skilled and competent to provide the alternative management plan.

Dr Amit Bhargava is a GP in Crawley, clinical chief officer of NHS Crawley CCG and a member of NHS Clinical Commissioners leadership group.

Dr John Canning: Discuss with partners, confirm the evidence basis and check with the LMC

Your first priority is to your patients and to Good Medical Practice. Reducing referrals merely to gain from an incentive scheme is not acceptable. However you also have responsibilities to use public funds properly, and the scheme set out by the CCG may have merit. The CCG should have a clear evidence base for its scheme, as the CCG leaders are also answerable to the GMC for their professional actions.

Your actions should be threefold: discuss the scheme with your partners or employing practice, approach the CCG for the evidence base and the LMC for its views on the scheme.

Some evidence is strong and based on clear consistent findings in two or more studies carried out within the UK and applicable to the target population, with evidence on salience and implementation. Other ‘evidence’ is inconsistent or non existent.

You should assess the evidence you have been given and - if you disagree with its interpretation or application - challenge the CCG. Your LMC should be able to provide you with support, or an explanation of the interpretation. (Any work you do to look at the evidence and your reflection on its application to your practice should be counted as CME/CPD time).

If you remain unhappy with the explanation, seek more detail and discuss the matter with colleagues both in general practice and ophthalmology. If a significant number of GP colleagues in the CCG are also concerned, you have a duty to challenge the CCG however uncomfortable this may be.

Dr John Canning is a GP in Middlesbrough and secretary of Cleveland LMC