GMC Should Rule On Referral Incentives, UK

Main Category: Primary Care / General Practice
Article Date: 28 Oct 2008 - 5:00 PDT


The government has told Primary Care Trusts that incentive schemes which pay GPs to cut referrals to hospital must be designed to ensure the best clinical care of patients.

After last week's revelations, that is an important first step.

Now the General Medical Council (GMC) should issue guidance on what is - and what is not - acceptable, the NHS Alliance says. That is the only way to make sure that the interests of patients are seen to come first, and that their doctors and primary care trusts are protected from accusations of bad practice, or even harming patients.

GMC rules say that doctors must not accept or offer any inducement that might affect - or be seen to affect - the way they treat or refer their patients. That appears to mean it is acceptable to pay incentives to GPs to review the way they refer. Regular review is good practice: it can highlight any issues about low referrals as well as high, educate doctors about possible alternatives to hospital treatment, and improve medical practice. But any doctor who accepted a payment to cut the numbers of referrals, or not to refer, might be acting wrongly.

In the absence of professional guidance, both GPs and PCT medical directors could stand accused of breaking GMC rules if a patient came to harm following a decision not to refer, even if that decision was in line with good practice.

Dr David Jenner, an NHS Alliance national executive member and a GP in Devon, said:

"We don't believe that doctors' decisions to refer are being influenced by incentive payments. That would clearly be wrong and in breach of the rules. However, the rules aren't just about accepting inducements. Doctors should not give the appearance of acting in a way that isn't in the patient's best interests. "These new schemes seem to be in a grey area that has never been considered before. The Sunday Telegraph has raised important issues that need to be addressed urgently.

"It is only the GMC who can issue professional guidance and they should do so immediately - not only for the sake of patients and their GPs, but also for PCT medical directors who could be accused of offering inducements."

Each first referral to hospital costs the NHS £100 - £200 per patient, depending on the speciality. That compares with around £25 for a GP consultation. It is well established that some referrals are clinically unnecessary and that numbers have gone up. The reduction in hospital waiting times means that many patients who would previously have opted for private treatment now prefer to stay in the NHS. At the same time, recent NICE guidance has encouraged GPs to refer more patients to specialist hospital care.

It is good practice for clinicians and PCTs to look at referrals. That can lead to services that are not just cheaper but better for patients. There has been no suggestion that any PCT is encouraging doctors not to refer when it is clinically appropriate to do so.

Notes

1. The NHS Alliance is a collaboration of clinicians, managers and board members who put patients first. It is the independent body that represents NHS primary care. Values based, it is the only organisation that brings together PCTs with GP practices, clinicians with managers and Board members, and NHS primary care with its patients. The Alliance membership and its hard working national executive is fully multi-professional.

2. The Department of Health wrote to all Strategic Health Authorities 24th October, saying that where incentive schemes are in place, primary care trusts should ensure that: "they do not in any way undermine - or be constructed in a way that could be perceived as undermining - the GP's overriding clinical and professional duty to provide the best care for each individual patient".

3. Under Conflicts of Interest, GMC rule 74 says: You must act in your patients' best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients. You must not offer such inducements to colleagues.

NHS Alliance

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