By saving on referrals, NHS is spending millions of pounds to GPs amid a backdrop of funding issues. Facing an ageing population and high migration rates, the health authority has been struggling with bed shortages and staffing crisis, along with long waiting times.

In view of its current situation, cutting costs via reducing patient numbers might appear a feasible solution. The head of NHS England, Simon Stevens, said last month that cancer care and A&E would be prioritised, and warned of longer waits for routine operations.

Meanwhile, many clinical commissioning groups (CCGs) - the NHS bodies responsible for planning and commissioning of healthcare in their local area - have initiated their own cost-saving schemes. They claimed the financial tokens were not conflicts of interest for doctors.

Two health trusts say schemes are extended to urgent cancer scans

A study showed that NHS forked out at least £57 million since April 2013, although the real sum could be higher, as a third of CCGs were unable to supply the figures. The British Medical Journal (BMJ) had sent freedom of information requests to all 211 CCGs in England, in which 72 out of the 184 who responded had commissioned some form of referral management scheme.

Though the majority of rewards were for non-urgent referrals like knee and hip replacements, cataract surgeries, hearing and blood tests, two CCGs have reported that the payments included urgent cancer tests in their schemes last year. One has not continued the incentives for this year while the other reported an increase in cancer referrals. Another two CCGs target heart operations or scans among the procedures.

According to BMJ, most CCGs could not provide evidence that the scheme saved money. Only 14% could show that the scheme had saved more cash than it had cost to operate, while 12% said that their schemes had not saved money overall.

Richard Vautrey, deputy chairman of the British Medical Association’s GPs committee, sees it as a very short-term approach to healthcare management. “We need to see much more evaluation … and not just keep making the same mistakes year after year. As public bodies, there should be an expectation on every CCG to account for what it is doing.”

In their defence, a spokesman from NHS said, “There are big variations in the extent to which different GP practices are able to provide services for their own patients at the local surgery without having to send patients to hospital, so it is often right to support these more convenient alternatives using the funding then not needed for unnecessary hospital outpatient visits.”

Cash incentives create “a conflict within consulting room”

While supporters believe the schemes can reduce inappropriate referrals, patient groups see it as ‘profoundly wrong’. The General Medical Council (GMC) states that doctors must not accept any “inducement, gift or hospitality” that affects or could be seen to affect the way a doctor treats or refers patients.

According to former Royal College of GPs chair and Lambeth GP professor Clare Gerada, such schemes risk interfering with the doctor-patient relationship. She said, “Once we start incentivising to reduce activity, then it puts a conflict within the consulting room.”

Professor Helen Stokes-Lampard, chairman of the Royal College of GPs, contended that GPs should always be able to act in the best interests of patients– and they must not be put in a position where they are asked to prioritise cost over the health and wellbeing of their patients. “Suggesting that we should behave otherwise is not only an offensive slur on our professionalism, but undermines the high levels of trust that exist between GPs and our patients,” she remarked.

Rosie Loftus, joint chief medical officer at Macmillan Cancer Support, felt that GPs could be put under pressure not to refer people who might have cancer, against their clinical judgment, because of targets. This, she said, is yet another sign of an NHS which is seriously overstretched and not giving GPs the resources and support they need.

Liberal Democrat leader Tim Farron said, ‘So we knew that the NHS was critically underfunded but now we learn that doctors are deliberately not referring people, and denying them the treatment they need, simply to save money. It looks like a bribe.’

Expressing concern, Dr Loftus said, “England’s cancer survival rates are already amongst the worst in Europe and a key reason for this is the inadequate access to cancer tests and treatment. If this is rationed further it could make survival rates and quality of life for people with cancer worse. This isn’t something the NHS can afford to do.” MIMS

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