Exclusive: Referral cuts by managers put GPs at risk of GMC investigation

GMC warning as GP investigation reveals extent of referral manipulation.

Dr Daryl Freeman: 'Referral decisions must be made on the basis of clinical need and we should be wary when clinical need is undermined by financial factors' (Photograph: NTI)
Dr Daryl Freeman: 'Referral decisions must be made on the basis of clinical need and we should be wary when clinical need is undermined by financial factors' (Photograph: NTI)

LMC leaders fear NHS cuts could put GPs in 'professional peril', as a GP investigation revealed how managers are systematically manipulating referrals to hit financial targets.

GPs face pressure to reduce referrals under the Quality, Innovation, Productivity and Prevention (QIPP) scheme, with targets to cut admissions included in the 2011/12 QOF.

GP referrals fell slightly in 2011 as a result, following rises of 6.4% in 2009 and 2.4% in 2010, DH data show.

But further DH data published this month reveal how GP referrals are being routinely managed in line with the financial year cycle.

Every year, the proportion of GP referrals that lead to hospital appointments falls by more than 10% in the run-up to the end of the financial year.

Dr Daryl Freeman, respiratory GP specialist for Norfolk, said that unless referral criteria were altered to produce such effects, she suspected non-clinical factors must be coming into play.

Risk of being struck off
London LMCs have warned that any GPs inappropriately failing to refer patients risk being struck off.

'The GMC will not forgive any GP whose patient has come to harm because they failed to refer when necessary,' the LMCs said in a statement.

Last July, the NHS Co-operation and Competition Panel warned that PCT referral management schemes were being used to extend waiting times, delaying treatment to save money.

This could well be a false economy, leading patients to require more complex and expensive care, the panel said.

Earlier this month, Barnet and Camden LMCs warned about risks after the introduction of schemes to cut GP referrals.

'While this may well be that GPs are simply using resources more effectively, we must remember we have a duty to refer when necessary, at our professional peril,' their newsletters said.

Northumberland LMC secretary Dr Jane Lothian said: 'People assume that if you optimise your existing pathways, referrals will go down, but I know of no evidence that if you adhere to best evidence, referrals will fall.

'The message we take is to reduce referrals where clinically appropriate and supported by education.'

Commenting on the findings, a DH spokesman said: ‘Decisions on appropriate referrals should be made by clinicians in the local NHS in line with the best available clinical evidence. The Department expects patients to receive the most clinically appropriate care at the right time in the most appropriate setting.’

Further analysis
The DH figures suggest that thousands of appointments every year are being delayed around the change-over between financial years. One reason for this could be that PCTs or hospital trusts are extending waiting times to delay treatment until the next financial year.

Last year, the Cooperation and Competition Panel warned that PCTs were increasing waiting times within targets, such as from 13 to 16 weeks, in order to help meet financial targets. Dr Freeman said the referral rates for individual practices would be too low for any GP to notice such a shift.

However, the data published by the DH allow an estimate to be calculated of how many patients are being affected by such measures. Assuming that referrals are delayed not cancelled, and that the average rate at which referrals lead to hospital appointments is the ‘clinically appropriate’ level, suggests that around 125,000 patients are having appointments delayed as a result of the manipulation of referrals each year. Assuming the highest rate at which referrals lead to hospital appointments is in fact the most appropriate would lead to an estimate of around 750,000 patients having their appointments delayed each year.

The data also reveal other peculiarities about the year-round differences in the rate at which GP referrals result in hospital appointments. For instance, the pattern of GP referrals rising and falling through the year follows a markedly different pattern to that of the fluctuation in GP referrals resulting in hospital visits across the year. In particular, during the summer and winter, when GP referrals rise, referrals are more likely than at other times of year to lead to hospital appointments. But, when GP referral rates rise around the end of the financial year, the proportion of referrals leading to hospital appointments falls.

The figures presented here do not take account of patients failing to attend appointments. They also do not consider the effect of the different number of working days each month and the time-lag between referrals being made and appointments taking place. Although data on ‘did not attend’ (DNA) rates are only published quarterly, rough estimates can be made of the effect of differences in the number of working days each month.  

The graph below uses data calculated on the basis that referrals lead to appointments in the following month. This is designed to represent the extreme case of how month-to-month differences working days could affect the proportion of GP referrals leading to appointments. This analysis suggests that differences in the number of working days leads to the overall U-shaped trend through the year and that filtering these out accentuates month-to-month differences.


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