Clinical Commissioning: North Durham

Roberta Blackman-Woods Excerpts

Wednesday 23rd November 2016 Westminster Hall

[Dr Roberta Blackman-Woods (City of Durham) (Lab)]

I beg to move,

That this House has considered changes in clinical commissioning group commissioning practices for GP referrals in North Durham.

I asked for this debate as a result of a development that affects many in my constituency and other constituencies covered by the North Durham clinical commissioning group. I was made aware of it not by the clinical commissioning group but by “BBC Look North”, which received a tip-off from a GP about an upcoming change to the way GPs refer patients to a specialist. The change made by North Durham CCG fundamentally alters the way in which a GP refers a patient to a specialist.

It was always the case that if a GP saw a patient and considered that their health condition needed further investigation, they would be able to refer that patient directly to a specialist. The scheme introduced by North Durham CCG adds an additional layer of referral: if a GP wants to refer a patient, they must send a letter and medical records explaining why to a private health company called About Health, which will decide whether a patient should be referred to a specialist. That means that, in effect, a private company that has never seen the patient can overrule the decision of the patient’s GP to refer them to a specialist in a hospital. Conditions that would be referred under the new system include cardiology, gynaecology, dermatology and gastroenterology. Suspected cancer cases would be excluded from the system, although many cancers are detected when patients present with other health issues.

The decision to implement the scheme was taken following a year-long trial carried out by North Tyneside CCG. We do not yet know the clinical outcomes of the patients involved in that trial, but North Durham decided to roll out the scheme even without that information. North Durham CCG’s decision to adopt the new practice for referrals was also made without proper consultation of local residents or patients. Many patients were not even informed that confidential information about their health status was being shared with a private company. My hon. Friend the Member for North Durham (Mr Jones) and I had a meeting with the clinical commissioning group in September, only weeks before it introduced the new scheme, and yet it made no mention of the scheme whatever.

[Liz McInnes (Heywood and Middleton) (Lab)]

I am listening to the debate with astonishment. General practitioners, by their very name, are generalists, are highly trained and should be aware of the signs and symptoms of diseases and know who to refer patients to, but the intervention of a private company has been inserted as a barrier to patients getting specialist treatment. I cannot believe what I am hearing. I am sure my hon. Friend shares my surprise.

[Dr Blackman-Woods]

My hon. Friend makes an excellent point. Indeed, I was shocked and surprised. In fact, when “BBC Look North” presented me with the information, my immediate reaction was of huge concern for my constituents. I did an interview for “BBC Look North” and was then contacted by other news outlets. As a result of those interviews, I was contacted by many of my constituents, some of whom had already been adversely affected by the new referral system, and by GPs who said they were being forced to jump through hoops or to refer their patients unnecessarily to physiotherapy services when they knew that treatment would not help before they could refer to a specialist in a hospital.

I was also contacted by a GP in the area covered by North Tyneside CCG who said that he had referred a patient to a specialist for a skin condition but the referral was overruled by the new scheme, which is called the referral management system. The skin condition turned out to be cancer, but that was not discovered until months further down the line, which meant that far more radical surgery was required than would have been the case if the patient had been seen by a specialist when the GP first referred them.

I therefore have a number of serious concerns about the referral system and the way in which the decision to implement it was made. My first concern is the possible negative impact on the health of my constituents and other people who live in areas affected by the new patient referral management schemes. I am concerned because whether a referral to a specialist goes ahead or not could have a long-term impact on the health of the patient or even result in something more serious, especially if decisions are overturned by About Health. A patient might not receive the treatment they need early enough.

I am also concerned about the financial impact of the decision. I understand that the NHS is under considerable financial pressure, but I doubt whether the scheme will end up saving money in the long run. That is because, as I just set out, in many cases where referrals are rejected the problem does not go away and patients return to their GP or even go to A&E with far more serious problems, which take up more of the NHS’ time and resources. About Health, the private company deciding on referrals, will be paid a basic fee and an additional £10 for each referral letter, which in itself will incur a significant cost. I am therefore not at all sure that the scheme is cost-effective.

My final concern is about the lack of public consultation and information on the decision to implement the scheme. Last October, the Secretary of State for Health announced plans to rate CCGs to make

“the most patient-focused NHS culture ever”,

which would be

“much more accountable to their local population than previously.”

The decision made by North Durham CCG to change completely the way in which GPs can refer a patient to a specialist without any consultation flies in the face of CCGs being accountable to the local population. How are people supposed to hold a CCG to account if they are not aware of changes that are being made?

The North Durham patient reference group meets monthly in Durham city to discuss patients’ points of view and give feedback to the CCG about proposals and issues. The group, which is drawn from members of each GP practice forum across Durham, was informed of the new referral scheme only as it was about to be introduced, and it was not given any opportunity to give feedback on proposals. Despite meeting monthly, members of the group had not even heard about the plans before they were presented with them and told that they were to be introduced imminently.

Similarly, members of patient forums at local GP practices were informed of the decision, rather than consulted on it. I am told that patient forums and the North Durham patient reference group were concerned and opposed the immediate implementation of the proposals, but North Durham CCG decided to go ahead and implement the new scheme immediately in any case.

This is a really important point for the Minister. If a patient goes on to the CCG’s website, what they see does not tell them that their details will be given to a private company; they are simply told that a referral system is in place and that referrals are to “consultants” or “specialist GPs”. I think many patients would conclude from that wording that their medical information is to be sent to a specialist at a local hospital rather than to a private company.

I have written to the CCGs in the north-east to invite them to meet me and other members of the northern group of MPs to discuss this issue. It has been extremely difficult to get them to come to a meeting with us or indeed to get any information from them at all. I have some questions, which I will put quickly, to give my hon. Friend the Member for North Durham time to speak. Does the Minister know of any other clinical commissioning groups in the UK that have implemented a patient referral management service? Does he think that it is acceptable that no consultation was carried out? Will the practice be repeated by other CCGs across the UK—particularly ones ranked as in special measures? How can About Health, or other private companies, be held accountable if decisions result in negative outcomes for the health of patients? Does the Minister agree that the referral system is acceptable at all?

[Geraint Davies (in the Chair)]

Both the Minister and the Member who moved the debate have agreed that Kevan Jones and Julie Cooper may speak, on the understanding that they will speak for under five minutes and two minutes respectively.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship today, Mr Davies. I, too, congratulate the hon. Member for City of Durham (Dr Blackman-Woods) on obtaining the debate, and I congratulate the other hon. Members who spoke too. It is good to have a chance to discuss the matter and weigh up the pros and cons of what is being done.

The context is the CCG in the hon. Lady’s area, which consists of 31 GP practices. It has been rated as a good CCG by the Care Quality Commission. Its treatment referral time is above the national standard, at 92% within 18 weeks. I want to talk first about the policy area, and then about the specifics of the decision to employ About Health in North Tyneside and North Durham.

The first thing to say about the policy is that referral management is not a new area. In 2007, something like 70% of primary care trusts had a type of referral management system in place. The intention is fairly clear: when a GP is making a referral, it will be absolutely obvious in many cases that it needs to happen. In many other cases it will be clear that a referral is not needed. There will also, frankly, be a grey area in the middle—that will happen in any profession.

[Dr Blackman-Woods]

Will the Minister focus on this specific referral system, under which, we understand, all referrals to specialists from GP practices in the CCG area are subject to private company screening and there is also a target to send back at least 50% of all referrals made?

[David Mowat]

I was explaining the purpose of the policy and the fact that this referral mechanism was used widely in 2007. A King’s Fund report from 2010 sets out the pros and cons of using referral management—I suggest the hon. Lady reads it.

These things are not new. They are a mechanism by which a consultant, or a GP with a specialist interest in the area of what is being referred—there are six areas of referral in this CCG, as the hon. Lady said—has two to three days to either accept that the referral goes on to the secondary system, or to contact the GP and have a discussion about what the best alternative pathway might be. There is an appeals process if the GP does not agree with that decision.

The hon. Lady asked where else such referral management was being done across the NHS in England. It was introduced in 2007, as I said, and it is being done very commonly. It is being done in Bromley, Cambridge, Peterborough, Imperial in London, and Southampton. I saw a similar system in Tower Hamlets to the one working in her area—indeed, the GP was very proud of the way they reacted, with an email referral system, when there was every possibility of things not going ahead.

This is not rationing. It is completely wrong to say that. It was brought in by the CCG, which is GP-led. If the GPs in the CCG do not agree with it, they have the mechanism to replace the chairman of the CCG.

--- Later in debate ---

[David Mowat]

I have given way a lot; I want to make some progress.

That is also of benefit to GPs, because they can quickly validate decisions on the best pathway for those grey areas that may or may not require a referral with a consultant who knows more than them about that particular discipline. Of course, it is of benefit to the providers because it takes away something like 20% of unnecessary outpatient appointments. Indeed, one of the providers for the scheme in North Tyneside has asked for it to be extended to an additional discipline, because they feel that some of the referrals they receive are unnecessary and that the referral management system—in the way we have been doing it in the NHS for the past decade—is a mechanism for preventing that.

[Dr Blackman-Woods]

The only information that North Tyneside CCG has put into the public domain is how much money it has saved through this system. It has not made an assessment of clinical outcomes for patients at all.

[David Mowat]

I am going to talk about the About Health situation and the people who have been awarded the contract in North Durham. It is a one-year pilot that builds on the one-year scheme in North Tyneside. I think it started last month; it covers six disciplines and it does not cover urgent referrals, in particular cancer. All the national requirements for referral-to-treatment times still count in exactly the same way. The local CCG performed a risk analysis before it decided to take the scheme forward and build on what happened in North Tyneside, and the scheme is monitored.

I have been told that a very important feature is that there is a clear GP appeals process. If they are not happy with a decision that has been taken, that process can happen very quickly.