GPs told all hospital referrals will be scrutinised in NHS money-saving measure, shows leaked memo

GPs are being told all their hospital referrals will be scrutinised by a panel of other doctors as part of a new bid to reduce costs, a leaked document has revealed.

A letter sent by NHS to England to Clinical Commissioning Groups (CCGs) and seen by Pulse magazine, asks that all family doctors in England to seek approval from a medical panel for all non-urgent hospital referrals.

A “clinical peer review of all referrals from general practice by September 2017”, will be required, it said.

To incentivise the scheme, it said that there will be “significant additional funding” for commissioners that establish peer review schemes this year. It added that it could reduce referral rates by up to by 30 per cent.

The new scheme covers GP requests for scores of procedures, including hip and knee surgery, cataract removals, X-rays and scans. If the panel disagrees with a doctor’s request, the patient is refused a hospital appointment.

An email seen by Pulse from NHS Bedfordshire CCG to commissioners on plans to scrutinise GPs' referral schemes says that it is “now an ask from NHS England” for them to ensure they have “100 per cent coverage of prospective peer review in practices”.

The email includes an attachment from NHS England on plans to incentives these peer review schemes.

“Significant additional funding is being given to regional teams in 2017/18 to roll out and spread interventions and schemes that will help CCGs to deliver a slower growth in referrals,” it says.

It adds that good practice would be for GPs to review each other’s new referrals at least once a week to ensure that “all options are explored and that patients are seen and treated in the right place, at the right time and as quickly as possible.”

But the guidance also makes clear that that the process “should not be established as an approval process” and the “referring GP retains responsibility for the patient and makes the final decision.”

Critics have warned the move could put patients at risk and delay essential treatment, with patients often sent for non-urgent tests are later discovered to have life-threatening conditions, including cancer and heart problems.

Professor Azeem Majeed, professor of primary care and head of the department of primary care and public health at Imperial College London, told Pulse that referral management schemes can sometimes “result in delays in referrals”, particularly when assessors are “not fully aware of the background to the referral”.

“To carry out effectively, clinical peer review requires adequate time and resources. Given the current pressures on NHS general practice in England, this scheme may well end up as a tick-box exercise rather than something that will improve patient outcomes and NHS efficiency,” he said.

GPC clinical lead Dr Andrew Green told the magazine he wished NHS England “put a tenth of the effort they expend on reducing pressure on hospitals into reducing pressure on GPs, which is the area of the health service with the biggest growth in workload.”

He added: “We are used to seeing un-referenced claims such as "could reduce by up to" in adverts for anti-wrinkle cream and I am surprised to see such language in an official document.

“It is important to be aware of the lost-opportunity costs of schemes like this, if we assume an hourly weekly meeting that would be equivalent to removing 1000 GPs from the English workforce, GPs we don’t have.”

An NHS England spokesperson said: "Clinical peer reviews are a simple way for GPs to support each other and help patients get the best care, from the right person, at the right time without having to make unnecessary trips to hospital.

“More than half of CCGs have already implemented some of peer review system, with Luton seeing an 8 per cent drop in hospital referrals, and the latest NHS England guidance will help ensure best practice is shared to remaining local commissioners."

A spokesperson at NHS Bedfordshire CCG said: “The executive team at NHS Bedfordshire CCG is currently in discussion with clinical leads on the implementation of the Clinical Peer Review system. Details of the agreed system will be advised in due course.”