My interest in the issue of outpatient follow-up began when my hospital trust asked me to reduce my ratio of new to follow-up consultations to 1:2.1 in 2006. Attempts to discover why led me to a new performance indicator from the NHS Institute for Innovation and Improvement; it appeared on the website as an “NHS better care, better value indicator.”

I am a rheumatologist. I deal with inflammatory joint disease, which according to specialty guidelines (endorsed by the National Institute for Health and Clinical Excellence) requires short term follow-up to stability, with appointments a month apart, and then specialist follow-up at least once a year. From my follow-up database I calculated that to achieve the trust’s target I would have to discharge half my patients. My trust managers said they were happy for me to do this because their GPs would have to re-refer them—and, by the by, said that I had no clinical responsibility for them. Re-referral would not only improve the ratio but also bring in extra money. (The Payment by Results tariff for a new patient consultation is £230 (€270; $360), that for a follow-up …