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GPs forced to ration access to hospital care

Rationing conflicts with role as patient advocate, finds BMJ investigation

Louise Prime

Thursday, 11 July 2013

GPs’ role as advocates for their patients is being undermined because they are now in the invidious position of having to ration access to hospital care, a BMJ investigation has found.

Investigators submitted freedom of information requests to clinical commissioning groups. The responses from 195 CCGs (out of 211 in England) revealed that, for 2013-14, one in seven have tightened the criteria for ‘low clinical value treatments’ – for example, cataract surgery, hip and knee surgery, tonsillectomies and IVF – many of which the Royal College of Surgeons say are proven to be effective in preventing complications later in patients’ lives.

Although a few CCGs are relying on better communication between primary and secondary care doctors to reduce costs, and have actually removed referral restrictions, some have tightened the thresholds for access to surgery; some have introduced new referral gateways to restrict the number of patients being sent to hospital; and “most … are dragging their feet” in implementing NICE’s new guidelines on wider access to in vitro fertilisation – only four told the BMJ that they have done so.

Authors of the report say that GPs are often put in a very difficult position by their CCG’s restrictions on referrals, as they find themselves writing a letter for an individual funding request for a patient’s treatment, while at the same time being committed to their CCG’s referrals policy.

They go on: “Many GPs have expressed concern that the profession is being set up to take the blame for rationing services in their new role as commissioners.” They point to NHS Crawley CCG, in West Sussex, where GP Jerry Luke recently resigned as clinical director, in part because of such concerns.

They write: “To date, Crawley has largely retained existing restrictions put in place by the previous PCT. But [Dr] Luke told the BMJ he was concerned that GPs have been placed in an invidious position … [as they] have a legal duty to break even.”

At the BMA’s annual conference of local medical committees in May, GPs overwhelmingly backed Dr Luke’s motion calling on the General Medical Council to ‘reaffirm that commissioning GPs’ primary responsibility is to their patients, not to financial balance’. Dr Luke warned delegates at that conference: “I fear without the GMC telling us our patients have to come first – before the money – we are going to be led by some of our colleagues who are quite happy to cut and slash just like the Department of Health wants. I personally am not prepared to carry on like this.”

Crawley CCG’s chief clinical officer, Amit Bhargava, told the BMJ, “We have always been clear about our responsibilities to our patients and have said to all our members that at no time should a GP or any other clinician refuse treatment to a patient based on cost alone.”

The investigators call for an open debate about doctors’ role in rationing NHS care in the new NHS and its conflict with their role as patient advocates – and said some doctors want there to be a defined, core list of NHS services available to all, to avoid a postcode lottery.

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