Leaked documents passed to The Times show that while ministers promise patients choice, a series of barriers are being erected limiting GPs’ rights to refer people to consultants.

The documents reveal that health trusts across London have drawn up plans to establish panels that will “monitor” how many patients are referred to hospital by GPs. Local health trusts have been told that they must cut GP referral rates to those of the lowest 10 per cent nationally. This, the document claims, would save £25 million a year in the capital.

Consultant-to-consultant referrals are also being limited, in many cases denying patients a second opinion.

Patients who use hospital accident and emergency units to obtain care that could be provided by GPs are also targeted. Emergency care practitioners in A&E departments will “redirect” 40-70 per cent of patients back to GPs or walk-in centres. Hospitals that treat people who ought to have been sent to their GPs will not be paid.

It is not known how many similar schemes are in existence, but the British Medical Association has confirmed it has found examples in Kent, Oxfordshire, Dorset, Wiltshire, Surrey, Sussex, Cornwall, Shropshire, Suffolk, Lancashire and Yorkshire, as well as London.

The draft paper, headed Pan London Demand Management Arrangements 06-07, says that Hammersmith and Fulham has found that a fifth of consultant-to-consultant referrals are “clinically not necessary”.

Matching that across London would save another £7 million, the paper says. But the bureacracy needed to screen all the referrals will itself cost £1.6 million. The London paper says that primary care trusts (PCTs) which cannot demonstrate that their referrals match the lowest 10 per cent nationally will be required to help to set up “review panels” in dermatology, ear, nose and throat, gynaecology, ophthalmology, rheumatology, trauma and orthopaedics.

These panels will review referrals by GPs, and cut them back. What this means is that patients will be denied appointments that their GPs believe they need. The language of the document makes no pretence that this will improve care, and emphasises cost savings throughout. “It is imperative that London balances its books overall,” the first paragraph says.

It also indicates that the measures proposed are “the bare minimum that we expect all PCTs to be doing”.

Urgent consultant-to-consultant referrals will be audited. “All urgent clinical referrals found to be clinically inappropriate will not be paid for by the PCT,” the document says.

The BMA yesterday condemned such schemes. Hamish Meldrum, the chairman of the association’s GP committee, said that they left patients in limbo, with no one clear where the responsibility lay if the condition worsened or the patient died.

Jonathan Fielden, deputy chairman of the BMA consultants committee, said: “It’s clear that clinicians don’t know how these referral management systems aid improvements in clinical care. To them they are purely cost-saving.

“The way they work is not transparent or clear. If clinicians don’t know, patients cannot know either. That certainly flies in the face of the Government’s Patient Choice agenda.”

Hospitals will also be penalised for the common practice of admitting people who have waited almost four hours in accident and emergency departments without being dealt with — thus avoiding the four-hour A&E target being breached.

The plan, which is still in draft, was produced by the London Transition Team, led by John Bacon, a senior NHS manager. It is typical of the action being taken nationally to save money by reducing referrals, or, putting it more plainly, treating fewer patients.

There are serious questions about whether such systems will work. say two experts in general practice in this week’s British Medical Journal.

Myfanwy Davies and Glyn Elwyn, of the Centre for Health Services Research at Cardiff, say there is little evidence that referral management centres work to improve the quality of referrals or save money.

They say that the centres have “appeared overnight in an evidence-free zone”.

Other doctors writing in the BMJ are even more critical. James Owen Drife, Professor of Obstetrics and Gynaecology at Leeds Teaching Hospitals, says that managing demand is an outmoded concept. “Firms which attract business are rewarded. Only the NHS keeps seeking ways of turning customers away,” he writes. “Or rather, only hospitals do.

“Enterprise culture is thriving in general practice, with its modern systems and motivated staff. But they have to interact with a hospital service that is as nimble and responsive as a Ukrainian tractor factory.”

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