Should GPs be paid to reduce unnecessary referrals?BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6148 (Published 17 November 2015) Cite this as: BMJ 2015;351:h6148
- David Shaw, senior research fellow, Institute for Biomedical Ethics, University of Basel, Switzerland,
- Peter Melton, chief clinical officer, North East Lincolnshire Clinical Commissioning Group
- Correspondence to: D Shaw , P Melton
A recent investigation by Pulse discovered that English clinical commissioning groups (CCGs) are offering rewards worth between £6000 (€8500; $9000) and £11 000 per practice to refer fewer patients for specialist consultations, scans, and operations.1 Maureen Baker, chair of the Royal College of General Practitioners, said: “This is a preposterous idea. 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.”2
Several of the nine CCGs involved have defended their reward schemes and denied that they create any conflicts of interest for GPs. But this confidence is misplaced. The General Medical Council guidelines state: “You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients . . . You must not ask for or accept—from patients, colleagues or others—any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients.”3
GMC guidance also says that health professionals faced with a conflict of interest must declare it4 and that doctors facing a conflict of interest must be prepared to exclude themselves from decision making. Are doctors really telling patients that they are receiving incentives for not referring them? Patients are bound to lose trust even if doctors do not change the way they refer.
Perhaps the worst aspect of these incentives is that they could lead to patients with cancer or other serious conditions not being referred when they should be. Although CCGs claim they are only trying to cut down on unnecessary referrals, it cannot be established that a referral for suspected cancer is unnecessary until the patient is referred and tests have been conducted. Any attempt to cut down on referrals risks missing important cases.
These incentives also seem to act against and undermine various initiatives to increase referral rates, particularly for cancer. Not to mention the cost implications: if a patient is not referred because of the incentives but turns out to have cancer, the treatment for a more advanced condition could be a lot more expensive. In some cases, however, not referring a patient could save the NHS money if a patient dies quickly for lack of diagnosis and treatment.
Doctors have a duty to report concerns about issues that could harm patients,5 and one local medical committee (Bolton) has indeed raised concerns with the GMC.1 The GMC has reportedly said that, although the incentives do not go against guidance, they would be considered inducement if GPs changed their behaviour as a result of them. But these schemes are designed to change GP behaviour—if they do not do so, they will have failed. Furthermore, the GMC’s response ignores the fact that even if behaviour is not changed, there is still a perceived conflict of interest, which must be declared according to its guidelines.
Why are doctors across England not up in arms about these policies and reporting CCGs to the GMC? Both GPs and the specialists who are not being referred patients have an obligation to raise concerns. Could it be that the failure to report the conflicts of interest raised by these incentives is due to a conflict of interests? Any GP who is successful in ending their CCG’s incentive policy stands to lose out on several thousand pounds a year. And who would want to do that?
It is misleading to describe schemes such as the one my CCG has introduced as incentives not to refer. They are designed to encourage improvement and support best clinical practice. We want to stop patients being referred to hospital unnecessarily when their condition could and should be investigated and resolved by their GP. This makes best use of NHS money but, more importantly, gives patients better quality care.6
Unnecessary referrals cause anxiety to patients, and the hospital is unable to focus on those it needs to treat. But there is often a cost to taking on additional responsibilities that needs to be supported, hence our local scheme.
Using financial incentives to encourage best practice is nothing new. The Commissioning for Quality and Innovation (CQUINs) payments framework links a proportion of income for secondary, community, and mental health services to local quality improvement goals.7 Some CCGs, including mine, have sought a way to do the same thing in primary care. The CCG asks practices to reduce the variation in activity between GPs by moving towards the referral rates of their best performing colleagues.
We drew on a King’s Fund inquiry into the quality of GP diagnosis and referral that found “financial incentives have been shown to alter behaviour and improve quality.”8 One study reported that incorporation of referral standards into GP contracts improves referral letters,9 while a primary care trust referral management system, driven by financial incentives, was effective in rerouting 50% of referrals to GPs with special interests.10
In 2010 our GPs agreed that under their contract up to 15% of their income would be subject to meeting locally agreed quality standards, including a range of targets such as uptake of cervical screening and implementing best practice on referrals. When the contracts were modified this year, GPs agreed to continue to have an element of practice funding linked to their ability to deliver good quality diagnosis and referral. GPs understand that not to seek to improve referral practice is ethically inappropriate. Success is measured by a reduced variation in referral behaviour, and any harm is measured by monitoring any increase in emergency department care or urgent admission resulting from late presentation. We also continue to measure and review patient complaints, numbers and extent of incidents across primary and secondary care, and any serious incidents.
In 1997 when I established the model locally for future primary care trusts, we explored concerns that GPs taking on local health budgets could stop appropriate referrals and prescribing. To reassure the public, we have a community governance scheme, and every piece of work has a GP, community representative, and manager lead, whose proposals go to an independent committee with a lay majority (excluding GPs who have potential conflicts of interest).
Our area’s success at all stages of cancer care recently received national attention.11 But improvements are still required. The relation between emergency admission and presentation of cancer is not necessarily a function of a low level of referral. Locally, there are practices with better outcomes that are at the lower end of the spectrum of referral numbers. The better outcomes are related to better working practices within primary care.
For example, we have operated a primary care led skin cancer service for many years with higher skilled GPs accepting referrals from colleagues who need a second opinion. They can either excise if non-malignant or refer to the acute setting with work-up and details in place. We are making an impact but more can be done: a 14-fold variation in dermatology referrals can result in unacceptably delayed access to a consultant.
The idea that GPs would consider restricting suspected cancer cases is misplaced, and a GP found to have acted in this way would face possible deregistration by the GMC.
Cite this as: BMJ 2015;351:h6148
Competing interests: Both authors have read and understood BMJ policy on declaration of interests and declare PM is chair of the NHS Commissioning Assembly and a director of Doc.know. He is a GP at Roxton Practice, which is a member of 360 Care and LINCS.
Provenance and peer review: Commissioned; not externally peer reviewed.