The BBC have quoted that in one case, Birmingham South Central CCG was offering practices more than £11,000 to reduce new outpatient attendances, follow-ups, A&E attendances and emergency admissions by 1%, compared with 2014/15 with their reasons being to "incentivise best quality practice" and "drive improvements in the quality of primary medical care. They say their priority is ''to ensure that patients have access to services that they need, when they need them."
Dr Chand Nagpaul, chairman of the GPs committee of the doctors' trade union the British Medical Association, told BBC Radio 4's Today programme that such schemes were a "financial contaminant" to patient-doctor trust.
He said:
"It's short-sighted and misguided of CCGs to introduce such mechanisms, because they do lead to the potential for patients questioning the motives of GP referrals. We believe it is far more appropriate for CCGs to introduce clinical pathways that ensure patients are referred appropriately rather than these crude, salesman-like bonuses which pay GPs simply to make reductions to referrals in numerical terms."
I am inclined to agree with this perspective. Though we are all hopeful that it would not happen, what is there to stop practices lowering the number of referrals they do make to ensure their practice is provided this extra financial aid. I agree that patients will question the level of trust they have with their GP if they are refused a referral. Will they understand it is because it is not necessary, or be concerned the GP is doing it for the financial reward? I also question if patients will feel they have to force a GP to refer them, when this should not be the case.
We are all well aware that the NHS is stretched, however I don’t see how a patient will have access to services they need if GPs are restrained from referring them. It's clear that the NHS needs to make savings, but I find it difficult to see how this will achieve that goal. Is it not better to refer early and rule out illness, reducing the care the patient will need in the future and ultimately save the NHS thousands of pounds by avoiding lengthy treatment and care plans?
Taking cancer for example, the UK has the worst cancer survival rates in Western Europe, due to late diagnosis. It is in all likelihood that this scheme will undoubtedly make this worse and we will see an increase in the percentage of late diagnoses and potentially the survival rates of cancer decreasing. I share the view of The General Medical Council, that this could cause a conflict of interest. I believe that the scheme would conflict with the recently announced cancer strategy, which ''promised 80 per cent increase in tests for cancers''. Reduced referrals surely mean there will be a decrease in tests. Again another question arises, does a decrease in tests mean a rise in late diagnoses?
Further, GMC guidance states that doctors cannot accept any ''inducement, gift or hospitality'' when they are deciding how to refer or treat a patient. It must be questioned whether being paid not to refer a patient is a breach of this guideline, although it appears it is the practice that received the financial benefit, not the specific GP. Dr Maureen Baker, chairman of the Royal College of GPs, 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. Most worryingly, it undermines the doctor-patient relationship and the trust that underpins it.” While she is clear that GPs will ''always make decisions in the best interests of our patients based on their clinical needs”,
implementing schemes such as this may lead one to argue this will not be the case and contradicts the Governments pledge for better healthcare.
Sean Duffy, National Clinical Director for cancer at NHS England said:
“We explicitly want to increase, not deter, appropriate referrals for cancer checks so as to ensure earlier diagnosis. But for some other conditions there’s clear evidence that by boosting funding of GP services, patients can get better care at their local surgery and avoid the need to go to hospital outpatients. The critical thing is to distinguish the two situations, which all GP-led CCGs must now ensure happens.”
It seems that distinguishing between not only these two situations, but whether or not a referral will occur at all will become increasingly difficult.