http://observer.guardian.co.uk/uk_news/story/0,,1939882,00.html

Managers block NHS access
Administrators are intercepting GPs' referrals and turning patients away
in a bid to save money

Jo Revill, health editor
Sunday November 5, 2006 The Observer

Thousands of patients are being denied access to hospital consultants
because the NHS has set up money-saving management schemes which block
GPs' referrals.

In direct contradiction to the government's claims to be encouraging more
choice in healthcare, patients with rheumatoid arthritis, knee problems
and eye and skin conditions are being targeted by managers who intercept
referral letters and send them back to GPs or into physiotherapy clinics
rather than allowing them to be seen by the appropriate specialist.

The scale of the interference has led some GPs to use extraordinary
subterfuges to get their patients to a surgeon. One practice in Merseyside
has decided to send letters marked 'private and confidential' to the
surgeons when they need a referral, rather than using the usual computer
system which would automatically block the request.

Another doctor told The Observer that he uses handwritten letters to
hospitals outside his area which he knows will not be blocked from taking
patients.

As the NHS struggles to deal with £620m of debt, administrators are using
referral management schemes to curb hospital admissions and to cut waiting
lists. The schemes start to operate once a GP sends an electronic letter
to a hospital consultant, requesting an appointment for the patient.

The letter is scanned by administrators who decide whether it constitutes
an 'appropriate' referral. If they deem it unnecessary, the patient is
'bounced' back to a clinic within the primary care trust, or to a nurse
manager or a physiotherapy clinic if it is an orthopaedic problem.

The British Medical Association has warned ministers that the plans are
threatening the relationship between a GP and patients, and that this goes
against the choice agenda even though the government is adamant that the
schemes can save millions of pounds.

Angry GPs in Merseyside are faxing referrals directly to a consultant to
stop managers intercepting them. They are also posting letters marked
'private and confidential' to prevent hospital staff from opening them,
and pushing patients back into the GP clinics. Doctors at a practice in St
Helens said they were forced to take the action after patients they had
referred for orthopaedic, rheumatology and physiotherapy were being
diverted away from Whiston Hospital in Prescot to a physiotherapy clinic.

A family doctor in Hertfordshire said that he had started to send
orthopaedic patients to a hospital outside their local area, so that he
knows they will see a surgeon. Dr Gerry Bulger is upset that his local
body, Dacorum primary care trust, set up a system which means that
patients with rheumatoid arthritis or orthopaedic problems cannot get an
appointment with a consultant; instead they are sent to see a
physiotherapist or another GP, who then decides what to do.

Dr Bulger said: 'Sometimes I write a hand-written letter to a hospital
which I know will accept them, to get round the diktat. How can the
government talk about giving patients choice when they are not allowed in
at the front door?'

Evidence from almost 100 PCTs found huge variations in the way GP
referrals are being handled, with some trusts using the centres to cut up
to 15 per cent of referrals. Orthopaedics, dermatology and physiotherapy
were the disciplines where referral management was most prevalent. As a
result, almost half the country's dermatology departments are suffering
from a huge loss of workload and some may have to close, as patients are
siphoned back into GP clinics.

Dr Jonathan Field, consultant leader for the BMA, said: 'Some of the
referrals from one consultant to another in the same hospital are now
being blocked, which is dangerous because it introduces really long
delays.'

In north London, all outpatient follow-up appointments are being stopped
unless the patient has cancer and GPs will be expected to check on
patients. All referrals for skin conditions are being banned unless GPs
stress it is urgent.

Enfield primary care trust is bringing in the measures in the next two
weeks to save £5.5m. Every referral to a hospital specialist is now being
screened by a panel of GPs, clinicians and hospital specialists under a
referral management system known as the Specialist Clinical Assessment
Service. A spokeswoman for Enfield primary care trust said the changes are
in line with government policy to encourage patients to be treated in
primary care near their homes.

A spokesperson for the Department of Health said: 'Referral management
schemes should ensure NHS patients see the most appropriate clinician in
the most convenient setting. These schemes must only be set up where they
will benefit patients.'