Financial incentives paid by NHS Hammersmith and Fulham Clinical Commissioning Group (CCG) to GP surgeries, encouraging them to cut outpatient referrals, almost doubled last year.
Several CCGs across the country have adopted referral management schemes, provoking concerns that patient safety and standards of care could be compromised and prompting NHS England to issue guidelines to reduce the risk of abuse to the system.
Figures obtained by a freedom of information request showed that in 2014/15 Hammersmith and Fulham CCG paid £87,178 to GP practices which moved towards the average referral rate. This was up from £47,552 in 2013/14.
Dr Maureen Baker, chair of the Royal College of General Practitioners (RCGP), was critical of such schemes: “It is deeply insulting and demeaning – as well as being highly unethical – to suggest that offering GPs money will change the way in which we care for our patients.
“Most worryingly, it undermines the doctor-patient relationship and the trust that underpins it.
“GPs are highly-trained and highly-skilled medical professionals who will always make decisions in the best interests of our patients based on their clinical needs.”
Although Hammersmith and Fulham CCG’s referral incentives budget in 2013/14 was £75,260, and was underspent by £27,708, the allocated investment was increased the next year to £128,000.
A Hammersmith and Fulham CCG spokesperson said: “Please note that the scheme under the GP Network Plan is not an incentive to ‘cut the number of patients attending hospital’ as you state in your question.
“It aims to reduce the variation in referrals and increase the use of appropriate community pathways.”
The scheme excludes urgent suspected cancer referrals.
A spokesperson for Save Our Hospitals, a resident-led campaign group established to fight the proposed closure of A&Es across south west London, said: “This raises a question about which we have very serious concerns.
“Individual patients may feel that they need specialist investigation/treatment but because of the structural imbalance in the doctor-patient relationship they may feel inhibited from pushing against GP advice that referral is not necessary.”
Research found that at least six CCGs in London offered GP practices incentives to reduce referrals.
Niall Dickson, chief executive of the General Medical Council, said: “Any doctor taking part in such a scheme should carefully consider our guidance when they make recommendations for treatment or referral.
“Financial and other incentives can be an effective way of driving improvements in healthcare, for example, where the goal is to encourage better use of limited resources and up-to-date clinical guidelines.
“But of course doctors need to satisfy themselves that the scheme will benefit their patients and that there is flexibility to meet the clinical needs of individuals,” he added.
“If a doctor does have concerns about a scheme, they should raise their concerns through the appropriate local and national channels.”
In October last year, NHS Lambeth CCG was reported to have an incentive scheme in place for reducing referrals.
In response to an FOI request, a Lambeth CCG spokesperson said: “NHS Lambeth CCG did not have a referral management scheme in 2013/14. The CCG paid £98,300 for ensuring best practice pathways were followed.
“This was part of the GP delivery scheme and this element was for keeping within the Practice indicative budget for GP outpatient, emergency admissions, and accident and emergency attendance.
In 2014/15, the CCG paid £325,214 for ‘ensuring best practice pathways were followed’.
The spokesperson said: “This was part of the GP delivery framework and this element was for working towards national top quartile rates of GP-initiated first outpatient attendance in secondary care.”
In response to CCGs offering financial incentives to practices to cut the number of referrals they make, NHS England has issued guidelines in a bid to reduce the risk of abuse to the system.
An NHS England spokesperson said: “NICE has set out evidence-based guidelines for when patients should be referred, and no CCG incentive scheme should in any way cut across that.
“We have contacted each of the CCGs mentioned to ensure this has been clearly communicated to all practices and will continue to monitor the situation.”
Picture courtesy of Lucas Hayas, with thanks