Chris Lancelot on the idiocy of quotas

Primary care organisations (PCOs) are asking GPs to reduce referrals by up to 40 per cent in order to balance their budgets. Some are even threatening to make practices pay for any referrals which are not on the PCO approved list - such as the removal of sebaceous cysts.

Have they thought through the legal and ethical implications of this? Failure to refer is one of the major reasons for complaints against GPs. If GPs comply with their PCO's demands, who is going to take legal responsibility if it eventually becomes clear that a particular patient should indeed have been referred? You can be certain that it will not be the PCO.

Doubtless many PCOs hold to the lay view of medicine, where everything is clear-cut: a coronary is a coronary, an ectopic is an ectopic, and doctors are incompetent if they cannot diagnose them with 100 per cent efficiency. As we all know, primary care medicine is not like this.

Symptoms and signs are frequently vague and GPs often have to weigh up the possibility that a serious condition may underlie apparently trivial symptoms. Resolving this uncertainty often requires hospital involvement. Even though a large proportion of such referrals will prove negative, they are all necessary.

What if you are not allowed to refer for the removal of a sebaceous cyst, know that you are not really competent to perform the operation, have a go (because the patient needs it doing), and make a complete mess of it? You will not have a leg to stand on because of our absolute duty to refer anything that we believe to be outside our level of competence. But who will take the blame?

If PCOs insist on imposing cuts in referral rates then many avoidable deaths will occur as early presentations of serious illness are overlooked; a huge rise in complaints will follow. GPs will be put in an impossible situation. If we choose to refer we will be penalised by our PCOs; yet if we fail to refer, we risk being sued by the patient or taken to the GMC.

Referral targets are contrary to all concepts of good medical practice, dangerous for patients, risky and stressful for GPs, and totally unethical. We must refuse to accept them.

- Dr Lancelot is a GP from Lancashire.

Email him at GPcolumnists@haynet.com

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