GPs put the squeeze on access to hospital care

BMJ 2013; 347 doi: (Published 10 July 2013) Cite this as: BMJ 2013;347:f4351
  1. Gareth Iacobucci
  1. 1BMJ

As GPs take over the lion’s share of the NHS budget, Gareth Iacobucci looks at how they are dealing with the difficult dilemmas of rationing

Clinical commissioning groups (CCGs) in England have begun implementing new restrictions on referrals to secondary care, as evidence emerges of the role that doctors are being forced to play in rationing NHS care, a BMJ investigation has found.

Some CCGs have tightened the thresholds for access to surgery, while others have introduced new referral gateways to restrict the number of patients being sent to hospital—as commissioners strive to manage their resources amid increasing financial restraints. Access to treatment for hernias, cataracts, and musculoskeletal conditions such as trigger finger have all been affected.

The BMJ’s investigation also found that most of the new GP led organisations, which assumed statutory responsibility for commissioning around £60bn (€70bn; $90bn) of NHS care on 1 April 2013, are dragging their feet in implementing new guidelines from the National Institute for Health and Care Excellence (NICE) designed to widen access to in vitro fertilisation (IVF), with only four CCGs having amended their policies so far.

One in seven CCGs in England tightened criteria for referring patients for so called low clinical value treatments in 2013-14. Many more have retained existing restrictions previously put in place by the predecessor organisations, the primary care trusts (PCTs), while others have opted for new triage systems to screen referrals from general practice and restrict the flow of activity towards secondary care.

But a few have removed referral restrictions that existed under PCTs and are relying on more streamlined communication between primary and secondary care doctors to drive down costs, highlighting the contrasting approaches being adopted to tackling the government’s target of achieving £20bn efficiency savings in the NHS in England by 2015.1

CCG leaders told the BMJ that all changes and new policies on whether to refer patients were primarily driven by clinical evidence and best practice and not by finance.

But the Royal College of Surgeons has argued that many of the procedures deemed of low value have been proved to be effective in preventing complications later in patients’ lives.

The findings have also reopened the debate about the role doctors are playing in rationing care in the new NHS, with one GP describing how he recently resigned as a clinical director of his CCG out of concern that his responsibility to help his commissioning group stay within budget was conflicting with his responsibilities towards his patients.

The BMA has urged the government and NHS England to give greater clarity and national guidance to protect doctors, amid growing fears that GPs’ commissioning decisions are conflicting with their primary role as advocates for their patients.

NHS England said it had an assurance process in place to ensure that CCGs delivered their “statutory duties in relation to quality of services” and said that ensuring effective use of resources should be “an established part of good clinical practice.”

Details obtained under freedom of information legislation by the BMJ from 195 of England’s 211 CCGs show that in many cases the organisations have adopted previous PCTs’ criteria for referring patients for procedures of low clinical priority, including cataract surgery, hip and knee surgery, tonsillectomies, and IVF.

But 27 CCGs (of 195 that replied) tightened one or more existing policies or introduced new restrictions. In total some 68 CCGs—including some that have already altered policies—are reviewing existing restrictions in one or more individual policies.

Tightening criteria for referral

Among the CCGs that have made changes is NHS Mid Essex CCG, which ratified a host of changes on 28 March 2013, including a new policy for restricting the surgical treatment of hernia. The policy restricts the availability of inguinal, umbilical, and incisional hernia surgery unless cases fulfil various criteria (depending on the type of hernia), including whether patients are experiencing symptoms, the hernia is increasing in size month on month, “appropriate conservative management” has been tried first, or the patient is currently asymptomatic but works in a heavy manual occupation where “there is a risk of strangulation and future complications.” It recommends that all suspected femoral hernias be referred to secondary care because of the increased risk of incarceration or strangulation.

Mid Essex also altered criteria for surgical intervention for procedures such as Dupuytren’s contracture, now funded only if patients have two or more affected joints rather than one and where the condition “is severely impacting on activity of daily living.”

Similarly, patients with trigger finger will qualify for surgical treatment only if they have failed to respond to conservative treatment, including up to two corticosteroid injections with at least a six week gap between injections or, again, if the condition is “severely impacting on activity of daily living.”

Elsewhere, NHS North East Hampshire and Farnham CCG, which said it was “working proactively” to agree a single set of guidelines with other CCGs in the region for a range of procedures, added a new restriction for 2013-14 stating that referrals to secondary care for skin lesions should be made only where there was “diagnostic doubt around malignancy.”

A spokesperson said a benchmarking exercise across Hampshire had shown the need to reduce “areas of unexplained clinical variation in both referral practice and surgical thresholds.”

Five other CCGs in Hampshire have altered criteria for referring for ganglions, hallux valgus, and grommets after “dialogue with local consultant surgeons” and amended skin lesions criteria “to ensure all referrals were made by the GP before the patient was seen in secondary care” and did not bypass primary care through a hospital emergency department.

Eight CCGs across northwest London added new restrictions for septorhinoplasty and a new general cosmetic policy but also removed restrictions on asymptomatic gall stones, caesarean section for non-medical reasons, erectile dysfunction drug treatment, foramen ovale closure for recurrent migraine, and therapeutic use of ultrasonography.

Lily Wong, medical adviser to the North West London Commissioning Support Unit, said local clinicians reviewed policies regularly “in line with national, evidence based guidance.”

Flouting NICE guidance

Besides tightening criteria for treatment, CCGs are saving money by dragging their feet on implementing NICE guidance. Under current rules the Department of Health requires that CCGs publish their level of compliance with NICE technology appraisals to ensure consistency across England.2 But this stipulation does not apply to NICE’s clinical guidelines and interventional procedures. For treatment such as IVF this has led to disparities in availability and levels of restriction across England.

To date, only four CCGs (Chiltern, Aylesbury Vale, Tameside and Glossop, and Stockport) have told the BMJ that they had altered their policy on IVF to reflect new NICE guidelines published in February,3 which advised that the age limit for women undergoing IVF be extended from 40 to 42 and that IVF be offered to single women and same sex couples (box 1).

Box 1: CCGs fail to implement NICE guidance on IVF

The vast majority of CCGs are yet to adopt new NICE guidelines advising that the age limit for women undergoing IVF be extended from 40 to 42 and that IVF be offered to single women and same sex couples. Only four have done so. A further 22 said they were reviewing their policies on IVF in light of the new guidance.

Among those that have rejected the NICE guidance is NHS Lancashire North CCG, which added new restrictions for 2013-14 on couples seeking IVF, including stipulations that the female partner cannot be over the age of 39 when starting treatment and that a couple cannot be referred if they have a living child whom they conceived together.

Cliff Elley, a GP in Lancaster and the GP commissioning lead for Lancashire North, said the starting point for setting policies was “always best evidence” but added that it was tough for CCGs to keep up with NICE guidance.

“It’s very difficult to keep up with the NICE guidance, because no sooner is one published then the next one comes out,” he said. “We would hope NICE would have a role in giving CCGs the information to say, on balance, whether something is a cost effective treatment. I think it would help CCGs.”

Elley added that localised commissioning would always lead to variation but said that Lancashire North had tried to avoid a postcode lottery situation by signing up to a Lancashire-wide policy covering several CCGs.

“If it [a particular referral process] becomes a national policy, commissioners on the ground feel they are not having input into that policy,” he said. “But if you break it [referral policy] down too small, the variation would be too large between each of these small organisations.”

Removing restrictions

In contrast to groups that have put new restrictions in place, other CCGs have removed restrictions to try to reduce the bureaucracy of the referrals process. NHS Chiltern CCG, in addition to removing the lower age limit for IVF in line with NICE guidance, has also allowed direct referral from the gynaecologist to the fertility specialist, rather than the case going back to the referral management system or GP, to “streamline the process.”

NHS Bassetlaw CCG, which is consulting on changes to its IVF policy in response to the NICE guidance, has removed all other restrictions on non-cosmetic, low value procedures for 2013-14.

Steve Kell, chairman of Bassetlaw and co-chairman of the national representative body NHS Clinical Commissioners, explained that his CCG was focusing on strengthening dialogue between GPs and consultants.

“It is really important that we have that level of trust in clinicians and that we discuss openly what we think is best practice across primary and secondary care,” he told the BMJ. “It’s the conversation that’s now happening that makes the difference.”

He added, “I don’t think this is saying that we will commission anything. Occasionally we will need to stop commissioning things, but when we do, that will be evidence based, it will be done for the right reasons, and we’ll do it in conjunction with local consultants to make sure the pathway improves.”

Introducing new referral gateways

Other CCGs have adopted new referral gateways to try to restrict the flow of patients being sent to hospital (box 2). NHS Stafford and Surrounds CCG and NHS Cannock Chase CCG, for example, have agreed with GPs to reduce referrals for a range of procedures to cut “unwarranted variation” and have implemented a new triage service for all musculoskeletal referrals.

Box 2: CCGs use new referral management systems

Some CCGs have implemented new referral gateways to try to restrict the flow of patients being sent to hospital.

NHS Chorley and Ribble CCG and NHS Greater Preston CCG’s joint gateway for processing all GP referrals is projected to save £20 703 a year in Chorley and Ribble and £25 499 in Greater Preston.

But Gora Bangi, a GP in Leyland and chairman of the Chorley and Ribble CCG, said the move was driven by quality, not cost, and would simplify the process so that GPs were clearer about the CCGs’ policies and the different options for referring.

“In some areas of secondary care we’ve got the highest elective intervention rates in the country, so we are very aware of the challenges that we face,” he said.

“The referral gateway was not introduced with a view to adjusting our management costs per se—it was initially a quality driven exercise, because we feel that the referral system is probably not robust and there is also variation.”

Since its introduction on a piloted basis in April, the gateway had returned 4% of roughly 13 500 referrals to GPs, Bangi said. He said that 1.8% (around 240) of the referrals were returned because of data quality issues, 1.2% (around 160) because they were duplicates, and 1% (around 140) because they were inappropriate, leaving 0.1% (around 14) specifically relating to decisions on treatments of limited clinical priority.

“We can make a lot of efficiencies and add value purely on clinical parameters,” Bangi added. He said that if the day came when they had to squeeze referrals purely to save money, the CCGs would ask to talk to NHS England.

Elsewhere, NHS Stafford and Surrounds CCG and NHS Cannock Chase CCG have agreed with GPs to reduce referrals for a range of procedures to reduce “unwarranted variation” and have implemented a new referral gateway for all musculoskeletal referrals, targeting reductions of 209 cases a year in Stafford and Surrounds (designed to save £214 203) and 198 in Cannock Chase (designed to save £209 300).

Andy Donald, chief accountable officer of both these CCGs, told the BMJ that all commissioning decisions made across the two groups, including targeted reductions in referrals, were signed off by a GP members’ board, giving them “clinical validity.”

Donald said substantial efficiency savings were achievable through smarter and more clinically appropriate commissioning, but he acknowledged that GPs’ new role as commissioners, providers, and advocates for their patients was “challenging.”

“We’ve got to help manage that set of tensions,” he said. “First and foremost the GPs are responsible for ensuring their patients get the best possible care. All we’re asking them to do is refer patients within guidelines based on the best clinical evidence available. Those are the guidelines that they have agreed and signed up to, not things we would impose.”

He added, “It isn’t about taking the money out. It’s about being able to be more efficient with the money we’ve got, and then we can reinvest it in more things.”

Dangers in restricting referrals

Although CCGs have said that their policies were underpinned by clinical evidence, the Royal College of Surgeons of England has argued that many of the procedures deemed of low clinical value have proved to be effective and prevent complications and more serious conditions developing later.4

Scarlett McNally, consultant orthopaedic surgeon and a member of the royal college’s council, warned that restrictions on procedures such as carpal tunnel decompression, trigger finger release, and hernia were denying patients treatment of proved effectiveness.

“Some of the procedures being termed as low clinical value are techniques that have been proven over years to be very helpful to most patients most of the time. Suddenly, lists are being produced that we haven’t had any input in suggesting that some procedures are not going to be commissioned for people in certain areas.”

McNally said that the development of restrictions and referral gateways without adequate input from surgeons could prevent patients from being assessed properly, which could exacerbate problems and lead to them needing more complex care.

“I looked at different lists from different places, and all of them contained procedures that actually do have benefit, maybe in the long term rather than the short term—for example, hernia repair,” she said. “If you’ve got a hernia, maybe you can wait a little bit longer, but it causes discomfort, and there is a risk of having a bowel obstruction. That’s a much more major operation.”

GPs’ coping strategies

In cases where treatments are subject to restrictions, GPs are able to make exceptional “individual funding requests” (IFRs) for patients who wish to access a particular treatment. In light of the growing number of restrictions, a survey by GP magazine last year found that numbers of IFRs had risen by 19% from 2010-11 to 2011-12, from 71 600 to 85 200.5

Cliff Elley, the GP commissioning lead for NHS North Lancashire CCG, acknowledged that this created some tensions in the new world. “It’s sometimes difficult if you are writing a letter [for an IFR] on the patient’s behalf, [when] at the same time you’re signed up to the policy [to restrict referrals],” he said. But while Elley said that GPs would benefit from CCGs “drawing a line in the sand” when difficult decisions had to be made, many others in the profession were concerned that GPs were being set up to take the blame for rationing care.

Resignation matters

Jerry Luke, a GP in Crawley, West Sussex, resigned as clinical director on the governing body of NHS Crawley CCG partly because of his concerns over rationing (box 3). Luke said that GPs had been placed in an invidious position and warned that CCGs could start running out of money later this year.

Box 3: Family doctor—patients’ advocate or guardian of the public purse?

Many GPs have expressed concern that the profession is being set up to take the blame for rationing services in their new role as commissioners.

Jerry Luke, a GP in Crawley, West Sussex, recently resigned as clinical director on the governing body of NHS Crawley CCG, in part because of his concerns over this issue.

To date, Crawley has largely retained existing restrictions put in place by the previous PCT. But Luke told the BMJ he was concerned that GPs have been placed in an invidious position.

“There is big reputational risk for those GPs that have tried to do this,” he warned. “If CCGs are truly clinically led, they will say no. But the ability to say no is massively curtailed. There is a constant top-slicing of budgets. There is massive pressure to refer in a certain fashion.

“Last year, PCTs were within budget. But it’s widely believed the plans for this year [across the country] will not deliver, and that somewhere between month 6 and month 9 CCGs are going to be running out of money. If the GPs are left to deal with it, there will either be slippage of services or budget. Up until now there have always been bailouts. But we have a legal duty to break even.”

Luke’s concern at the situation prompted him to propose a motion at the BMA’s annual conference of local medical committees in May, overwhelmingly backed by the GPs in attendance, calling on the General Medical Council to “reaffirm that commissioning GPs’ primary responsibility is to their patients, not to financial balance.”

At the conference, Luke warned, “I fear without the GMC telling us our patients have to come first—before the money—we are going to be led by some of our colleagues who are quite happy to cut and slash just like the Department of Health wants. I personally am not prepared to carry on like this.

“I’ve been up close and personal to the decisions CCGs have to make. They have only one real duty, and that is to end the year in budget. Everything else is secondary to that. You’ll hear from the advocates of clinical commissioning that it is outcome focused and clinically appropriate. Do not be seduced by snake oil salesmen. CCGs can run out of services, but they cannot run out of money.”

Responding to Luke’s concerns, Crawley CCG’s chief clinical officer, Amit Bhargava, said in a statement to the BMJ, “We have always been clear about our responsibilities to our patients and have said to all our members that at no time should a GP or any other clinician refuse treatment to a patient based on cost alone.”

NHS core services

With some GPs reluctant to ration care and set new thresholds, the BMJ investigation raises the question of whether the government, in collaboration with the medical profession and the public, should draw up a list of core services for the NHS.

Chaand Nagpaul, a GP in Harrow and lead negotiator on commissioning for the BMA’s General Practitioners Committee, said that the government’s reorganisation of the NHS had created “an extra challenge” for GPs. He said that CCGs should not have been given the responsibility of setting treatment thresholds locally but that it should be up to NHS England to set national thresholds to ensure consistency.

“The right thing is to remove the decision from the direct CCG,” he said. “There is a need to ensure equity within the system and avoid a postcode lottery where the patient is at the mercy of CCG finances.”

At its annual representatives meeting last month BMA members supported a motion calling on the association to launch a debate with the public and the health professions about how the health service they want in the future could be delivered “in a climate of shrinking resources.”

Gordon Matthews, a consultant orthopaedic surgeon from Buckinghamshire and a member of the BMA’s Consultants Committee, who proposed the motion, said it was “essential that a list of core NHS services available to all is defined” so as to avoid a postcode lottery.

Will the government step in?

But the government seems to have little appetite for arbitrating on CCGs’ decisions. Back in July 2012 the former health secretary Andrew Lansley pledged to investigate alleged examples of rationing of NHS treatment.6 But a Department of Health response to a freedom of information request from the BMJ showed that no formal inquiry or investigation into this issue ever took place. The department’s response said that Lansley did investigate a specific claim that one PCT was rationing cataract surgery but said he was satisfied that there were “no grounds for the assertion.”

An NHS England spokeswoman said that CCGs’ commissioning policies should “be consistent with NICE guidance where applicable, or best available evidence of clinical and cost effectiveness”—and that it would ensure CCGs could access NICE’s Medicines and Prescribing Centre for “a range of supportive advice on safe decision making.”

The spokeswoman said that NHS England had not offered any guidance to CCGs on how to introduce new commissioning policies and would not mediate in cases where local clinicians disagreed on whether a treatment was cost effective.

She said, “CCGs are responsible for explaining the reasons for their commissioning decisions. We may intervene where we believe a CCG is failing, or at risk of failing, to meet its statutory duties. This may include where a CCG has failed to follow a proper process in reaching decisions on the funding of a particular treatment or drug.”


Cite this as: BMJ 2013;347:f4351



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