General Practitioners (GPs) in the UK are being offered cash payments as incentive to not refer patients to hospitals – including cancer patients – according to an investigation by Pulse, a website for GPs.

It was discovered that four NHS clinical commissioning groups (CCGs) have been using “profit share” initiatives to ration care, to help them operate within their budgets. CCGs hold the budget for the NHS locally and decide which services are provided for patients.

Through this scheme, GPs are told they will receive up to half of the money that is saved by fewer patients going to hospitals for tests and treatments.

Understandably, this has led to a fierce row with Dr Peter Swinyard, chair of the Family Doctor Association, who called the scheme a “serious dereliction of duty” and other experts expressing that it is “ethically questionable”.


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GPs could keep up to 50% of savings made

Pulse used Freedom of Information disclosures to obtain information about the scheme from 181 CCGs and their findings illustrated how it varied across the country. Of the 180 which responded, only 24% had a scheme. Eleven were involved in direct incentives to GPs, while four were involved in “profit-sharing” schemes.

NHS Coastal West Sussex and Enfield CCGs told their practices that they could keep 50% of the savings made. West Leicestershire practices were given 30%, whilst Rotherham’s GPs received GBP3.36 per patient – not excluding cancer patients. Equally startling, is the Barnsley scheme which located GBP1.4m to pay its practices if they achieved a reduction in referrals to specialties – including cardiology, pancreatic surgery, trauma and orthopaedics.

The cost of NHS care varies depending on the procedures. Source: National Tariff for 2017/18/The Independent
The cost of NHS care varies depending on the procedures. Source: National Tariff for 2017/18/The Independent

No win-win solution: Balancing budget and quality patient care

The schemes could greatly impact patient care and once again, betray the trust a patient has, for his or her doctor. Swinyard explained that, “from a patient perspective, it means GPs are paid to not look after them.”

The Department of Health and Social Care agreed, saying, “patients must never have their access to necessary care restricted – we would expect local commissioning groups and NHS England to intervene immediately if this were the case.”

GP leaders also said that it is “insulting” to the doctors themselves to suggest that they are sending patients to hospital arbitrarily. Helen Stokes-Lampard, chair of the Royal College of GPs, echoed that “cash incentives based on how many referrals GPs make have no place in the NHS, and erode the trust our patients have in us to do what is best for them and their health.”

NHS has had referral management centres in place since 2003, and their job is to independently review GP referrals. However, last year they were at the epicentre of a scandal when it was revealed that the use of these centres has increased 10-fold since 2005. Furthermore, the centres are privately run and extremely expensive to employ.

Those who were reviewing the referrals were also found to have varying levels of clinical knowledge, and so were not always able to correctly identify which referrals were necessary. They were also extremely inefficient as patients were forced to wait a long time for appointments.

Dr Chaand Nagpaul from the British Medical Association said performance seems to be based on reducing referrals rather than patient care. Photo credit: BBC
Dr Chaand Nagpaul from the British Medical Association said performance seems to be based on reducing referrals rather than patient care. Photo credit: BBC

Dr Chaand Nagpaul, from the British Medical Association (BMA) pointed out that “It’s a blunt instrument which is not sensitive to the needs of the patient and is delaying patient care.

“It has become totally mechanistic. It’s either administrative or not necessary for the patient. It’s completely unacceptable. Performance seems to be related to blocking referrals rather than patient care.”

But, the CCGs are defending themselves, stating that the NHS is currently struggling through the worst winter ever in its history and have not been able to hit target waiting times since 2015. The CCGs have said that the scheme is only to help reducing unnecessary referrals and therefore improve outcomes for genuine patients, and not to reduce numbers overall.

Are there any other solutions?

In response to the general squeeze on the NHS, other efforts to stay within budget include the shift of many specialist treatments from hospitals to GP clinics – such as diabetes clinics. These shifts not only help with long queues, but also save money – because unlike hospitals, GPs are not paid per procedure. Rather, they receive a single payment when each patient is registered with them.

NHS England has also said that they want to introduce a “peer review scheme” whereby GPs check the referrals of one another to ensure they are appropriate. However, experts warn this could lead to more problems and possible conflict.

Campaign group, 38 Degrees, set up a petition to abolish cash-for-cut referral schemes – expressing that the “plan is dangerous” – and aims to “stop the scheme before it spreads across England.” Photo credit: Screenshot from 38 Degrees
Campaign group, 38 Degrees, set up a petition to abolish cash-for-cut referral schemes – expressing that the “plan is dangerous” – and aims to “stop the scheme before it spreads across England.” Photo credit: Screenshot from 38 Degrees

For now, over 100,000 people have signed a petition to stop the cash-for-cuts referral scheme , set to be sent to Health Secretary, Jeremy Hunt.

“When you walk into your doctor’s office, you want to know your GP is only thinking about giving you the care you need, not the money they can save or the targets they have to hit,” expressed the campaign group behind the petition, 38 Degrees. MIMS

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Sources:
https://inews.co.uk/news/health/gp-practices-cash-for-cuts-scheme/
https://www.theguardian.com/society/2018/feb/28/gps-offered-cash-to-refer-fewer-people-to-hospital
http://www.independent.co.uk/news/health/nhs-gp-savings-sick-patients-operations-avoid-hospital-treatment-reward-cash-a8231591.html
http://www.pulsetoday.co.uk/hot-topics/cash-for-cuts/over-100000-sign-petition-against-cash-for-cuts-gp-referral-schemes/20036266.article
http://www.bbc.co.uk/news/uk-england-38372332