There’s been a predictable outbreak of spluttering over the news that GPs have been offered money to refer fewer patients to specialist care, including those with suspected cancer.
The payments – uncovered by health industry magazine Pulse – come from clinical commissioning groups (CCGs), the local bodies responsible for organising and purchasing healthcare for the NHS. But it is not clear how many have introduced incentives, and different groups have adopted different approaches.
Birmingham South Central CCG has been relatively gentle, effectively offering £11,000 to practices for achieving a 1% reduction in their referral and emergency admission rates. North-East Lincolnshire, in contrast, is offering less – £6,000 – but demanding much more: a reduction of referral rates to the level of the lowest referring 25% of practices.
Both the British Medical Association and the Royal College of GPs have raised ethical concerns about the general approach. Critics claim the incentives create a fundamental conflict of interest and contradict the teachings of Good Medical Practice – the profession’s ethical bible. Specifically, they highlight the prohibition on doctors accepting any inducement that may affect how they “prescribe for, treat or refer patients or commission services for patients”.
But the critics are on treacherous ground here. Doctors are already subject to a range of implicit and explicit incentives that profoundly shape their behaviour, many of them written into existing contracts. The most obvious of these is the Quality and Outcomes Framework (QOF), a financial incentive scheme introduced in 2004 that rewards general practices on the basis of their performance against over 100 quality indicators.
These include targets for immunising patients against influenza, prescribing beta blockers to patients with coronary heart disease, and referring patients with angina to a specialist. These targets were introduced to encourage practices to increase their activity where it is too low.
There is no qualitative difference between this and offering practices incentives to reduce their activity where it is too high. And throughout the history of the NHS there have been implicit incentives that do just this. The bulk of funding for general practices still comes through capitation payments, which effectively reward practices for withholding care and have helped to make the NHS one of the world’s most efficient healthcare systems.
Where a treatment or service is available, providing access is generally seen as a good thing and denying access as bad. With respect to referrals, little harm is directly inflicted on the patient in providing a specialist assessment or investigation. But a delay in diagnosis could reduce the chances of a successful outcome.
The problem is offering unlimited access to healthcare – whether or not it’s really needed – comes with costs for both the patient, through anxiety and risks from investigative procedures, and the rest of the system. NHS resources are finite and under increasing pressure, and unnecessary referrals deplete these resources, effectively denying care to others.
Perhaps recognising this, Niall Dickson, chief executive of the General Medical Council, has chosen his words on the issue very carefully: “Financial and other incentives can be an effective way of driving improvements in health care, for example, where the goal is to encourage better use of limited resources and up-to-date clinical guidelines.”
The fundamental difficulty is working out how to move GPs towards an appropriate level of activity, which will differ depending on the local population and circumstances. This requires sophisticated tools to identify and then increase appropriate referrals while decreasing inappropriate ones.
However, the tools taken up by some CCGs bear more resemblance to bludgeons, and they are likely to have unintended consequences. For example, the Birmingham South Central scheme lumps emergency admissions in with routine referrals, but by delaying specialist assessment and treatment GPs may increase the risk of an emergency admission.
If a scheme such as that in North-East Lincolnshire were to rely on crude referral rates, driving all practices down to the level of the lowest referrers could severely disadvantage deprived populations. Poorer people are more likely to get sick, and practices serving poorer populations would legitimately expect to refer more patients than practices serving affluent populations.
Unless there is appropriate risk adjustment, such schemes could widen health inequalities. CCGs would also need to consider separating different types of referrals so that these schemes do not conflict with other initiatives – for example the drive to increase rapid cancer referrals.
Crucially, these incentives also raise the question of whether patients can trust their GPs to act in their best interests. This will require a wider public debate, but this should encompass all of the incentives GPs are subject to, both explicit and implicit.