Family doctors are receiving cash bonuses not to send patients to hospital despite National Health Service research that suggests incentive payments can reduce the quality of care.

GPs are paid £1 per patient to spend time reviewing their decision to send someone to hospital and a further £1 for every name on their surgeries’ list if they reduce their previous year’s referral rate. An average surgery with 10,000 patients will receive up to £20,000 for taking part in the scheme.

Eighty out of 82 practices in the Oxfordshire Primary Care Trust area signed up for it this month. Similar incentive schemes have been set up across the country despite the NHS’s National Institute for Health Research (NIHR) giving a warning about the risks. “Financial incentives to encourage GPs to reduce referral rates can be effective, but this is a high risk,” it says. It concludes that reduction “may apply to both necessary and unnecessary referrals”.

Oxfordshire PCT introduced cash incentives after a rise of 8 per cent last year in the number of referrals to Oxford Radcliffe Hospital NHS Trust and Nuffield Orthopaedic Centre NHS Trust. Nationally, hospital referral rates increased by 16 per cent.

If doctors hit their targets, then the PCT will be left with a bill of £1.2 million. However, the trust believes that the expense is justified because the increasing amount of patients being sent to hospital is estimated to cost £6 million.

GP surgeries across London, Essex, Oxfordshire, Devon and Wiltshire are said to have signed up to incentive schemes that are at least partly based on reducing hospital referrals.

Laurence Buckman, chairman of the British Medical Association’s GP Committee, said: “I don’t think patients’ services should be treated as a commodity which is incentivised if you don’t do something. A large number of patients are referred to hospital for investigation. If you don’t know what’s wrong, you cannot know how to handle the problem.”

Martin Roland, who led the NIHR investigators, said yesterday that patients were right to be worried about payments to GPs simply for meeting quotas on reducing referrals.

“If [the payment] triggers some sort of thoughtful process, such as talking to a more experienced colleague, then that is commendable and may save unnecessary referrals,” said Professor Roland, director of the National Primary Care Research and Development Centre. “But I would be cautious about incentives simply to reduce numbers if they are not tied to some sort of clinical review. The danger is that patients who would benefit from referral to hospital would no longer be referred.”

Sue Woollacott, chairman of the Patient Support Group at Nuffield Orthopaedic Centre, said: “It seems to imply that GPs aren’t making good judgments and need financial incentives in order to do that. If I were a GP and getting payments for the practice, it would seem like some sort of bribe.”

Andrew Lansley, the Shadow Health Secretary, said that it was “inefficient and unethical” to pay GPs to refer fewer patients to hospital. “If patients find out that their local health bureaucracy is paying their GP not to refer them to hospital they will be rightly outraged,” he said.

The schemes come after the Government’s admission that the average GP now earns more than £103,000 but that patients in two-thirds of primary care trusts cannot see their doctor within 48 hours.

Stephen Richards, chairman of the clinical executive for Oxfordshire PCT, said its research on 120 patients referred to hospital dermatology clinics found that at least half could have safely been seen by community-based services. “Junior, less experienced doctors do have higher referral rates than their more experienced colleagues and one of the focuses of our schemes is to encourage discussion with senior doctors with these relatively less experienced doctors,” he said. “By insisting that a senior colleague is doing a review of the decision-making progress, we are extremely unlikely not to refer someone who needs to be referred.”

A Department of Health spokesman said: “Most people prefer to be treated at home or in the community rather than in hospital if possible. GPs should base their referral decisions on what is clinically appropriate.”

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