Intended for healthcare professionals

Head To Head

Should GPs be paid to reduce unnecessary referrals?

BMJ 2015; 351 doi: (Published 17 November 2015) Cite this as: BMJ 2015;351:h6148
  1. David Shaw, senior research fellow, Institute for Biomedical Ethics, University of Basel, Switzerland,
  2. Peter Melton, chief clinical officer, North East Lincolnshire Clinical Commissioning Group
  1. Correspondence to: D Shaw{at}, P Melton peter.melton{at}

David Shaw is concerned that such payments will lead to missed diagnoses and loss of trust, but Peter Melton says that with proper safeguards they will improve patient care

No—David Shaw

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 …

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