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Plans to ban GP referrals will ‘worsen long-term costs and patient backlog’

Suspending all non-urgent referrals to hospitals made by GPs in order to ease pressure during winter months will only damage public trust and create a backlog of patients needing to be seen come springtime, the Royal College of GPs (RCGP) has said in response to controversial financial recovery proposals from a Merseyside CCG.

In its Financial Recovery Plan, published last week, St Helens CCG listed a number of proposals designed to salvage its economy in light of necessary savings and an expected £12.5m funding gap.

Its chair, Geoffrey Appleton, who is inviting feedback on the plan, conceded that the proposals “will not be popular” – but said efficiency savings alone will not suffice to plug the CCG’s expected funding gap.

Faced with the prospect of suspending, reducing or withdrawing certain services entirely, one of the proposals in the plan – and the one that has received the most criticism this week – is the suggestion to temporarily suspend non-urgent referrals to hospital for a maximum four-month period.

Described as one of the biggest areas of financial pressure, with current activity in local hospitals exceeding their budgets, the CCG said it believed a four-month pause on non-urgent treatment would “have a number of additional benefits”.

These include supporting hospitals during busy winter months when there is a marked increase in demand; enabling hospitals to concentrate on patients needing urgent care; and reducing the risk of operations being cancelled when there are less non-urgent beds available.

Justifying the CCG’s proposals, Appleton said: “To explain it in simple terms, imagine our NHS budget is your household budget and every year the cost of living goes up but your salary doesn’t increase; the result is money becomes tighter and tighter. Now imagine another relative comes to live with you and because of their health needs are unable to work and cannot contribute financially. How would you manage?

“Although we have proactively been working with NHS England to reach a solution, our organisation still faces a funding gap of £12.5m over the next year and this is going to result in some tough choices about what is affordable for our local population. We would prefer not to be in this position but we are by no means alone as an increasing number of CCGs are reporting similar financial challenges.”

Proposals are ‘yet another sign’ of desperate underfunding

The proposal was met with harsh criticism. Dr Maureen Baker, chair of the RCGP, said GPs only make referrals when they think it is necessary and questioned whether a blanket ban on non-urgent referrals “is the best way to ease potential pressures” over winter.

“Such a scheme would potentially damage the high levels of trust patients have in their GP, if they think their condition isn’t being taken seriously, and will simply cause a backlog of patients needing to be seen by specialists come springtime, when the colder weather conditions have improved,” she continued. “There are also patient safety implications, as patients with potentially serious conditions sit on waiting lists without their symptoms being explored further.”

Ultimately what is needed, Dr Baker added, is for decision-makers to “factor in general practice” when putting together plans and allocating resources for the winter period.

Similarly, Dr Richard Vautrey, deputy chair of the BMA’s GP committee, said it “cannot be right that the public will be effectively denied access to healthcare because the local CCG has run out of money”.

“What apparently may not be urgent at first presentation and is therefore not referred could turn out to be very serious in the long term. Many cases of cancer are subsequently diagnosed following routine referrals of patients who have undifferentiated symptoms early on in their illness,” he added.

“The cost to the health service of delaying referrals could ultimately be much greater in the long term as more complex and costly problems develop as a result.

“This is yet another sign of how desperately under-funded the NHS now is and how the government need to step up their commitment to resolving this crisis.”

St Helens CCG, which was rated ‘inadequate’ by NHS England this year, also proposed stopping the provision of OTC/minor ailment medicines for short-term conditions; stop providing gluten-free foods on prescription; and stopping routinely commissioned specialist fertility services by placing restrictions on age referral criteria.

Despite the public outcry, an NHS spokeswoman said decisions when prioritising resources are “always very difficult for commissioners” but said it was up to CCGs to make the best decisions for their area alongside the local hospitals.

“St Helens CCG is actively engaging with its local population on the best way to ensure patients have their care prioritised over the busy months for the NHS,” she added. “The 18-week target is a national objective which all CCGs and hospitals should be striving to meet.”


Phil Barber FRCP   10/08/2016 at 16:21

Delaying referrals does not reduce cost, it increases it. Waiting, waiting, waiting, is aleady welded into the DNA of the NHS, and is hopelessly counterproductive and inefficient, not to mention demoralising for staff and patients. Patients need to be seen and treated as they present - good medicine (and surgery), efficient and effective, also allowing the true funding needs to be clearly measured and addressed - often a matter of process and attitude rather than resources. A number of systemic problems have contributed to this crisis. First is the clockwatching and bureaucratic system of job-planning and time management that has been forced on consultants, with the apparent support of the Colleges and the BMA, rather than the creation of a workforce of sufficient size, flexibility, authority and commitment to handle the work, come what may. Another is the surrender of work planning and priority to managers who look only in one direction (upwards) for their priorities, rather than to the needs of the service on the ground. Third is the clear political direction of the current administration, who would like ultimately to dismantle and privatise health care. On the other hand, however, there is also a reluctance among NHS enthusiasts to consider new and better ways of working, and especially to look at the healthcare systems of other nations. The current problems could never arise, for example, in France, and would not be tolerated by a public with much higher expectations for consultant-led specialist care, rather than the systems of 'triage', delegation, upward filtration and barefoot doctoring we have come to regard as high-quality healthcare but which is badly failing our patients. Perhaps one could finally draw attention to the incredible waste of workforce and resources which would result from an elective freeze, leaving the pieces to be picked up at a later date: short-termism gone mad. Yes, macro funding is indeed an issue, but it is not the only one.

A Moore   11/08/2016 at 08:17

The general quality of NHS management (including the DoH Civil Servants who advise etc Ministers) must surely be drawn into the discussion? Can we wonder about how we came to this situation with Secondary Care managers whose inadequacies and inflated salaries are plastered all over the media on an almost daily basis, NHSE managers whose understanding of how Primary Care works is highly suspect (as anyone in GP-land is well aware) and central bureaucrats who have displayed the paucity of their knowledge as was displayed when they drew up the original 2004 contract? GP practices operate with a management hierarchy so flat it is almost non-existent yet the clear direction is to force them into organisational structures with more management levels. Surely the time has come to examine the way the NHS is structured because even though some management has probably been cut there surely must be a rebalancing in favour of clinicians and simpler structures.

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