Letters Peer review of GP referrals

Outsourcing review of GP referrals to private companies: who ultimately gains?

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4607 (Published 11 October 2017) Cite this as: BMJ 2017;359:j4607
  1. Nick Mann, GP
  1. London E9 7TA, UK
  1. drnickmann{at}gmail.com

We GPs in Hackney had compulsory clinical peer review of our referrals (with payment by results linked to “quality”) imposed on us a few years ago.1 Our referral rates are rising, perhaps more slowly than they otherwise might have done, and cost and quality have not noticeably improved. By preventing some unnecessary referrals and saving money, we might also have delayed some diagnoses and caused harm to patients.

This is the daily risk balance that GPs are trained to manage in a cost conscious manner. General practice does work well: it is both cheap and cost effective.

Our practice loses 12 appointment slots a week—three per doctor—to fulfil peer review. In this brave new world of managed care, precious time for clinical discussion has all but disappeared.

A third of clinical commissioning groups have contracted screening referrals to private companies, which reject referrals repeatedly. Who screens these referrals and on what criteria? Are there penalties for missing targets on reducing referral numbers, like at the Department for Work and Pensions? Is that safe or ethical? Do they know what it feels like to face patients who have had missed diagnoses? How many lawsuits from patients for delayed or missed diagnosis would it take to offset any potential savings from this scheme? The GP, not the referral company, will be liable in any such lawsuit.

This is certainly not the model of peer learning that referral screening is mooted to encourage. Who ultimately gains?

With the NHS already dangerously under capacity, most GPs cannot keep taking on more clinical responsibilities. Outsourcing referral screening will add no clinical value, cost more, and might ultimately increase harms to patients. It de-professionalises doctors and puts “profit wonks” in charge of medical pathways.



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