NHS GP practices offered cash rewards to not send patients to hospital

'Cash incentives based on how many referrals GPs make have no place in the NHS,' GP leaders say

GPs could benefit from a 50 per cent cut of any savings they make by not sending patients to hospital (PA)

Doctors’ surgeries are being offered rewards for not sending patients to hospital, in a move condemned as a “dereliction of duty” by experts.

An investigation into referral incentive schemes being run by NHS clinical commissioning groups (CCGs) across England found some regions offering GPs as much as 50 per cent of any savings they can make.

These “profit-share” arrangements mean practices stand to benefit financially by not sending patients for treatment or to see a specialist.

Hospitals are paid for operations and other activity, so by sending patients to cheaper services or by keeping them out of hospital altogether, practices can increase the size of savings.

Other CCG areas offer a payment of up to £5 for every patient registered at the practice if it can cut its referrals by 10 per cent on the previous year.

CCGs have claimed that these schemes are intended to “improve the quality of referrals” and ensure patients are seen at the best service for their needs, rather than trying to reduce numbers overall.

But GP leaders said it is “insulting” to suggest doctors are sending patients to hospital arbitrarily, and raise significant conflicts of interest.

“Cash incentives based on how many referrals GPs make have no place in the NHS, and frankly, it is insulting to suggest otherwise,” said Professor Helen Stokes-Lampard, chair of the Royal College of GPs.

“Of course, it’s important to take measures to ensure that GP referrals are appropriate and high-quality, but payments to reduce referrals would fly in the face of this, and erode the trust our patients have in us to do what is best for them and their health.”

The NHS has been squeezed for increasingly drastic efficiency savings in the past eight years.

A major response to this has been to move specialist treatment which would once have only been possible in hospitals – such as diabetes management – to GP practices and community-run services wherever possible.

This frees up hospital capacity, and is also cheaper because GPs are not paid solely for each procedure they perform they receive a payment for each patient registered with them instead.

NHS England also said last year that funding will be available for CCGs to start “peer review schemes”, where GPs check their colleagues are referring appropriately, but it is not clear what it thinks about direct payments linked to cutting referrals.

The “Cash for Cuts” investigation, by GP publication Pulse, asked all 207 CCGs in England about their processes for cutting referrals.

Of the 180 who responded, 24 per cent had some kind of incentive scheme aimed at lowering the numbers of referrals.

This could include payments for getting GPs to “peer review” each other’s referrals or other strategies not aimed at directly cutting numbers.

What does NHS care cost?

The cost of each type of appointment is largely set in the NHS Tariff, which shows the amount a hospital will be paid for a procedure or appointment with each type of specialist.

Tariff prices for elective procedures that might be included in incentive schemes:

£5,431 entry price for a relatively uncomplicated hip replacement 

£1,363 for a complex cataract procedure

£133 for a dermatology appointment

£120 for a first visit to a children’s ear, nose and throat specialist

£119 for a MRI scan (plus £22 for reporting results)

£90 for acupuncture for pain management
Source: National Tariff for 2017/18

NHS Coastal West Sussex CCG told Pulse it is offering its practices – which work in networks covering 30,000 patients – 50 per cent of any savings they can make on the previous year’s elective (planned) spending.

The CCG said GPs should refer in their best clinical judgement and that the funds they make should be used for schemes which will improve access to GP services or help it hire more staff.

While West Leicestershire CCG offered a 30 per cent cut on the savings from a reduction in the bill for first outpatient referrals.

Similar schemes are in effect or being developed in Wolverhampton, the Vale of York, and Enfield – which is proposing to share savings with the whole area.

Dr Peter Swinyard, chair of the Family Doctor Association, said the profit-share schemes were “bizarre”, adding: “From a patient perspective, it means GPs are paid to not look after them.

“It’s a serious dereliction of duty, influenced by CCGs trying to balance their books.”

Meanwhile, NHS Barnsley CCG has identified a £1.4m funding pot to pay its practices if they achieve a reduction in referrals to specialties, including cardiology, pancreatic surgery, and trauma and orthopaedics.

The CCG said the 10 per cent target was “ambitious but achievable”.

It told Pulse: “Ensuring treatment is based on the best clinical evidence and improving historical variation in access is essential for us locally.

“Financially, it is an effective use of local resources which will improve patient experience and outcomes and increase investment in primary care in line with the Five Year Forward View commitments.”

But Dr Dean Eggitt, who is the British Medical Association’s GP representative for Barnsley, Doncaster, Rotherham and Sheffield, disagreed.

“The scheme is unsafe and needs to be reviewed urgently,” he said.

The BMA’s GP committee said that it had raised concerns nationally where CCGs have set an “arbitrary target” for reducing referrals.

The health service is currently struggling through the worst winter crisis in its history, and key waiting times targets have not been hit since 2015.

Before Christmas, Jeremy Hunt, the Health Secretary, announced he wanted hospitals to find another £300m in savings on items like surgical gloves and bandages, and a long-awaited pay rise for nurses is contingent on staff boosting “productivity”.

A Dapertment of Health and Social Care spokesperson said: "Patients must never have their access to necessary care restricted - we would expect local clinical commissioning groups and NHS England to intervene immediately if this were the case."

NHS England was asked by The Independent whether it would be reviewing cases where GPs stand to profit financially for not referring patients, but it had not responded at time of publication.