Are NHS GP Practices Still Offered Financial Incentives to Reduce Hospital Referrals? Focus on Physiotherapy

In recent years, NHS GP practices across England have been offered various financial incentives to reduce the number of patient referrals to hospital-based services, including physiotherapy. These schemes, part of a broader strategy to improve efficiency and manage healthcare costs, have sparked both support and controversy within the medical community.

Mechanism of Financial Incentives

The incentive schemes work by rewarding GP practices for cutting down on hospital referrals. Two primary forms of these incentives are the "savings share" and "fixed payments" models.

Savings Share Model

The "savings share" model is a financial incentive where GP practices receive a portion of the cost savings achieved by reducing hospital referrals. This model operates on the principle that by minimizing unnecessary referrals, the healthcare system can save significant amounts of money, which can then be partially redistributed to the participating practices.

For example, Coastal West Sussex Clinical Commissioning Group (CCG) offers GP practices 50% of any savings made from the previous year’s elective spending. This means if a practice reduces its hospital referrals significantly and saves the CCG money, it receives half of those savings as a financial reward. This scheme is designed to encourage GPs to consider alternative, cost-effective treatment options within primary care settings before opting for hospital referrals.

Fixed Payments

The "fixed payments" model provides a more straightforward financial reward system. Under this model, GP practices receive fixed payments for achieving specific targets in reducing hospital referrals. This scheme is simpler as it offers a set amount of money per registered patient or per reduction achieved.

For instance, some regions provide practices up to £5 per registered patient if they reduce referrals by 10% compared to the previous year. This payment is a direct financial incentive for practices to lower their referral rates. The fixed payment model is easier to administer and provides clear financial goals for GP practices.

Direct Access to Physiotherapy

One notable implementation of these schemes is the integration of musculoskeletal first contact physiotherapists within GP practices. This initiative allows patients with back, neck, or joint pain to see a physiotherapist directly, bypassing the need for a GP referral. This approach not only reduces the number of hospital referrals but also provides quicker access to care for patients. By 2024, it is expected that all adults in England will be able to access a musculoskeletal physiotherapist directly through their GP practice.

Benefits of the Scheme

The primary benefits of these schemes include cost efficiency, quicker access to care, and better workload management for GPs. Managing conditions such as back pain and arthritis within primary care is less expensive and can be more timely than hospital-based treatments. Patients benefit from faster diagnoses and treatments, potentially improving health outcomes and reducing the burden on secondary care services.

Cost of Employing Physiotherapists

Employing a physiotherapist within a GP practice comes with its own costs. On average, the salary for a physiotherapist in the UK ranges from £25,000 to £45,000 annually, depending on their level of experience and specialization. Additionally, there are associated costs for training, equipment, and administrative support. Despite these expenses, the integration of physiotherapists is seen as a cost-effective measure in the long run due to the reduction in hospital referrals and the ability to manage more conditions within primary care.

The document "Unit Costs of Health and Social Care 2022" provides detailed information on the costs associated with various health and social care services, including physiotherapy. According to the document, the average cost per session of physiotherapy in the NHS is £92. When delivered one-to-one, the cost increases to £144 per session. These costs are derived from the National Cost Collection for the NHS 2020/2021 and have been adjusted to 2021/2022 prices using the NHS Cost Inflation Index.

Criticisms and Concerns

Despite the potential benefits, these incentive schemes have faced significant criticism. Medical professionals and patient advocacy groups argue that financial incentives could lead to under-referral, where GPs might avoid sending patients for necessary hospital tests and treatments to gain financial rewards. This is particularly concerning for physiotherapy services. Conditions that could benefit from early intervention, such as musculoskeletal issues, might worsen if not referred promptly. Delayed diagnoses and treatments can result in more severe complications and chronic pain, ultimately increasing the burden on the healthcare system.

The Royal College of General Practitioners has condemned these schemes, stating that financial motivations should not influence clinical decisions. They argue that such incentives erode the trust patients have in their GPs and may compromise the quality of care.

Regulatory Oversight and Future Directions

In response to these concerns, NHS England has been actively reviewing these incentive schemes. A consultation on the role of incentive schemes in general practice is ongoing, with feedback being sought on whether these schemes should continue to form part of the income for general practice. This consultation will help shape the future of these schemes and ensure they do not negatively impact patient care.

Moreover, the new GP contract for 2024/25 includes updates aimed at supporting general practices in delivering high-quality care. This includes an overall increase in investment and specific funding for integrating roles such as physiotherapists within primary care settings. These measures are designed to improve access to care, manage workloads more effectively, and ensure that financial incentives do not compromise patient care.

GP Earnings and Transparency

All GP practices are required to declare the mean earnings for GPs delivering NHS services. This move towards greater transparency allows patients to understand how their GPs are compensated. For example, the average pay for GPs working at Springfield Surgery in Bingley, West Yorkshire, in the last financial year was £56,043 before tax and National Insurance. This figure is for three full-time GPs and four part-time GPs who worked at the practice for more than six months. These examples will vary from surgery to surgery.

GPs do not work under standardized contracts or funding, and practice income varies greatly from area to area. The average GP practice receives around £136 per patient per year to provide services, while Springfield Surgery receives £95.43 per patient per year.

Declaring GP Earnings Over £150,000

In addition to general earnings transparency, GPs with NHS earnings exceeding £150,000 are required to self-declare their earnings annually. This requirement, part of the General Medical Services (GMS) and Primary Medical Services (PMS) regulations, aims to increase transparency in GP pay but has been met with resistance from the medical community.

The British Medical Association (BMA) has expressed concerns that this policy could lead to increased aggression and abuse towards GPs and negatively impact morale and recruitment. The earnings threshold for mandatory declaration is set to rise annually, with GPs earning over £159,000 required to declare their income for the 2022/23 financial year.

It is important to note that physiotherapists are not required to declare their salaries, which provides a contrast to the transparency requirements imposed on GPs.

The practice of offering financial incentives to GPs for reducing hospital referrals, including for physiotherapy, remains a contentious issue. While aimed at improving efficiency and reducing costs, these schemes must be carefully managed to ensure that they do not adversely affect patient care. The potential risk of under-referral, including physiotherapy, can lead to severe long-term health consequences for patients. Ongoing reviews and consultations will be crucial in shaping the future of these practices, ensuring that patient health remains the primary focus of the NHS.

References

1. Coastal West Sussex Clinical Commissioning Group. (2024). Coastal West Sussex CCG

2. NHS England. (2024). Financial Incentive Schemes. NHS England

3. NHS Long Term Plan. (2024). Musculoskeletal Health. NHS Long Term Plan

4. Prospects.ac.uk. (2024). Physiotherapist: Job profile.

5. PSSRU. (2022). Unit Costs of Health and Social Care 2022.

6. National Cost Collection for the NHS. (2022). NHS Digital

7. Pulse Today. (2024). Cash for Cuts: Referral Incentive Schemes. Pulse Today

8. Royal College of General Practitioners. (2024). Position on Financial Incentives. RCGP

9. NHS England. (2024). Consultation on Financial Incentives. NHS England

10. BMA. (2024). GP Contract 2024/25. BMA

11. Springfield Surgery. (2023). Earnings Report. Springfield Surgery

12. NHS Digital. (2023). GP Practice Funding. NHS Digital

13. NHS England. (2023). GP Earnings Declaration. NHS England

14. BMA. (2023). Position on Earnings Declaration. BMA