How your GP is paid to stop you going to hospital

By Victoria Ward

GPs are being offered bonuses to reduce the number of patients sent to hospital, including those with suspected cancer, an investigation has found.

Family doctors are being paid bonuses worth thousands of pounds to keep within targets for outpatient referrals and follow-ups, which can include two-week cancer waits and emergency admissions.

The British Medical Association's general practitioners committee (GPC) said such schemes could be “ethically questionable” while Macmillan Cancer Support said it was “very worrying” that GPs could be put under pressure not to refer people against their clinical judgment because of targets.

The schemes are also at odds with the recently announced NHS Cancer Strategy which promised an 80 per cent increase in tests for cancers. The UK has the worst survival rates for cancers in Western Europe, largely due to late diagnosis.

The General Medical Council (GMC) has already looked into one such scheme and raised concerns that the payments could be regarded as inducement if it was felt they had influenced a GP’s behaviour.

The research, by Pulse magazine, found that Clinical Commissioning Groups (CCGs), the NHS bodies responsible for the planning and commissioning of regional healthcare, in nine parts of the country were offering GP practices financial incentives to cut referrals.

GMC guidance states that doctors must not accept any "inducement, gift or hospitality" that affects or could be seen to affect the way a doctor treats or refers patients.

But as the NHS in England attempts to save £22 billion by 2020, the Freedom of Information study indicates how standards in routine, front-line care are being jeopardised.

It found that the NHS North-East Lincolnshire CCG is offering the average practice the equivalent of more than £6,000 to reduce outpatient referrals, including two-week urgent cancer referrals, to the same level as the 25 per cent of practices with the lowest referral rates in 2014/15.

NHS Birmingham South Central CCG is offering the average practice the equivalent of more than £11,000 to reduce new outpatient attendances, follow-ups, A&E attendances and emergency admissions by one per cent, compared with last year.

The CCG said it had considered the “full impact” of the incentive scheme and was “confident that there is no conflict of interest”.

“These (schemes) may, at face value, potentially be ethically questionable and conflict with GMC guidance."

In London, at least six CCGs offer incentives for practices to reduce referrals.

Among them, NHS Hammersmith and Fulham CCG has made available a total of £107,600 across all practices for reductions in referrals.

NHS Lambeth CCG is offering payments to practices which move towards the average 2014/15 referral rate per 1,000 patients.

The CCG claimed that urgent care and two-week cancer referrals “cannot be separated” from the overall numbers.

But Dr Emma Rowley-Conwy, a Lambeth, south London, GP, warned that such targets were “counter to other initiatives that encourage GPs to refer earlier for suspected cancers”.

NHS Bolton CCG sought guidance from the GMC over its “quality contract” which pays practices for reducing referrals for procedures of ‘limited clinical value’ by 20 per cent and for reducing first outpatient appointments and follow-ups by 1 per cent.

Dr Rosie Loftus, joint chief medical officer at Macmillan, said: “This is yet another sign of an NHS which is seriously over stretched and not giving GPs the resources and support they need.

“England’s cancer survival rates are already amongst the worst in Europe and a key reason for this is the inadequate access to cancer tests and treatment. If this is rationed further it could make survival rates and quality of life for people with cancer worse. This isn’t something the NHS can afford to do.”

Dr Robert Morley, chair of the GPC’s contracts and regulations subcommittee, told Pulse that schemes incentivising practices to reduce urgent cancer referrals were “extremely concerning”.

He added: “These may, at face value, potentially be ethically questionable and conflict with GMC guidance, on the basis that they might conceivably influence individual management decisions.”

Former Royal College of GPs chairwoman and Lambeth GP Professor Clare Gerada said such schemes risk "interfering with the doctor-patient relationship".

She added: "Once we start incentivising to reduce activity, then it puts a conflict within the consulting room."

The Patients Association also warned that such incentives posed an inherent risk to patients.

“If we start incentivising so that we can achieve targets, but actually we are not providing the most appropriate care, then it brings into question good practice guidelines,” a spokeswoman said.

“We should never focus on targets and financial gain over clinical outcomes.”

In July, the NHS pledged major reforms to the way it diagnoses and treats cancer, leading to an 80 per cent increase in the number of cancer tests, with all patients given a definitive diagnosis within a month by 2020.

Simon Stevens, chief executive of NHS England, said the £2 billion initiative would also replace a range of outdated equipment and mean that the UK has a “world class” cancer service within five years.

The largest ever cancer study revealed last month that the UK’s cancer survival rates are a third lower than those in Sweden.

The report, presented to the European Cancer Congress in Vienna, showed that despite investment in attempts to diagnose cases earlier, and speed up access to treatment, there has been no narrowing of the gap between Britain and other developed nations.

Experts said the major differences reflected poor rates of early diagnosis in this country, with one in five cancers not spotted until a patient arrives at Accident & Emergency departments.

Some of the CCGs said they were focused on cutting "unnecessary" referrals. Others had much broader targets to cut referrals for "high activity" specialties.

Some argued that the incentives represented no conflict of interest for doctors and that they were simply reducing the huge variations in referral rates between practices.

Some of the CCGs that provided details to Pulse said they were focused on cutting "unnecessary" referrals. Others had much broader targets to cut referrals for "high activity" specialties.

They have not yet responded to requests for comment from the Telegraph./Telegraph