The real reasons behind doctors’ hospital referrals
Monday 8th February 2010, 2:59PM GMT.
From Dr Bryony Perchard.
I WRITE on behalf of the Jersey Primary Care Body, the organisation which represents the Island’s GPs. We were extremely concerned to read in the recently published addendum to the Verita report the allegation that local GPs refer patients to hospital consultants for financial reward.
We would like to reassure our patients and the public that this is entirely incorrect. When a GP makes a referral to the hospital, he or she receives £15 from the Department of Employment and Social Security and additionally may make a further charge to cover the doctor’s time in preparing the referral (ensuring that the appropriate clinical information is disclosed, such as the scope of the problem, pre-existing medical problems, medications, allergies etc), together with secretarial fees, postage and all other costs associated with generating a letter.
A recent audit showed these costs to be in the region of £30 per referral. No financial gain is made, there being no additional incentive payment for the task.
Having reviewed the otherwise excellent and extensive report, the initial referral by Elizabeth Rourke’s GP, Dr Wilson, was reported as entirely appropriate. Section 7.4 of the main Verita report states: ‘This was an entirely proper action for Dr Wilson to take. He could have offered Mrs Rourke treatment to try to help with her symptoms, but seeking an expert opinion was appropriate because it might help to decide what treatment to offer.’
The statement made in the addendum of the report suggests that according to the subjective view of some hospital staff, Jersey GPs make higher than the UK average referral rates to the hospital. Should this be the case – and there is no objective evidence disclosed in the report – this may be for a multitude of reasons.
GP referrals to the Hospital do highlight one of the problems associated with Jersey’s health care system that may contribute to the suggested higher than national average hospital referral rate. Unfortunately, patients have to pay to see their GP, but they do not have to pay to see a consultant (although they do pay through their taxes). As a result of this system, GPs are sometimes under pressure by patients to refer to the hospital.
It may be the case that the problem could have been dealt with by the GP practice, but this would obviously incur ongoing costs to the patient.
Therefore, there is an incentive for referral from some patients who may be struggling with their medical bills and would like to be seen in the ‘free’ hospital rather than by their GP. This may result in a GP practice losing income by referring patients to the hospital, rather than gaining any.
As GPs, our primary concern is to promote the best interests of our patients, having made a clinical assessment of need, coupled with their concerns and expectations.
Residents of Jersey are used to having good access to the Hospital and being able to see consultants promptly. As the population increases, and with it expectations of improved health, this will put the Hospital under more pressure. This will be increased by the ageing population. We are very willing to contribute to efforts by the States to resolve some of these issues and are in consultation to improve medical care provision in the Island.
We hope this letter goes some way towards reassuring our patients. We look forward to the States and Hospital authorities promptly addressing the recommendations of the Verita report and would welcome the opportunity to meet Verita to discuss the concerns that have been raised.
We are committed to improving the health of the Island, and strive to avoid such a tragedy happening again.
The Queen's Diamond Jubilee
JEP Jubilee Editions
Saturday 2 June: Guide to Celebrations
Wednesday 6 June: Souvenir of Events
View The Queen in Jersey supplement
Travel
To, from and around the Island
Airport Arrivals/Departures
Harbours Arrivals/Departures
Bus Information/Timetables
This is Jersey
Jersey Evening Post
Useful links
So let’s see, let’s say a GP sees one patient every half hour from 9-5 taking an hour’s break for lunch, this would mean he/she would see 14 patients a day on average.
Let’s say the Doctor refers only half of them every day and gains £30 each time for having their secretary write a letter on their behalf and signing it.
If we do our maths this would mean that a Doctor would receive £4200 in the course of a month in referral fees alone – I’m sure however that there’s no financial incentive to refer patients!
V.
Report abuse
Dear Vendetta
I think you should check your figures.
If each GP on this Island referred 7 patients a day in an ordinary working week that would result in around 170 000 referrals a year, rather than the 11000 referrals the hospital actually receives. Additionally an experienced full time medical secretary costs in the region of £30 000 per annum. With each GP referring around 115 patients a year the fee for a letter just covers the cost of the secretary’s salary, stationary, postage, computer, electricity, building rent and all the other associated costs required to employ staff and provide good medical care.
Report abuse
Dear V, you seem to forget that from that £4200 must come the salary for the secretary, the salary for the GP, overheads for the surgery and other costs incurred by running a business ie very high insurance costs etc. It is not easy money and it is also against a GPs code of conduct to refer a patient for unnecassary treatment etc
Report abuse
Dear x,
You seem to forget that the GP is paid for the consultation anyway so any money for referrals is over and above their usual salary.
In any case if for example this pays the secretary’s wages, then the only consequence of that is that the GP gets a free secretary, hardly a great burden!
As for the whole “they’d never do it because it’s against the rules” argument I think you’d find that there are a few people who might find this reasoning a little weak, particularly those whose MPs have claimed thousands in false expenses.
Still as Harold Shipman’s widow will tell you, the medical profession is exempt from anyone who would attempt to embezzle money fradulently on behalf of their patients.
V.
Report abuse
Dear V,
Although you have very valid thoughts, Harold Shipman is one GP out of many.
X
Report abuse
So am I to understand this, what you’re saying is that given what I said is true the Doctor in question would have to settle for a free secretary instead of cash? How on earth will they cope.
However House suggests I check my figures and as such I thought I’d do a little homework given the extorbitant costs you mention.
The cost of the secretary, building, electricity and so on is irrelevant. A Doctor would require such amenities to practise whether they received a referral fee or not and they are amply paid for by the fact that the State and the patient pay the Doctor for each appointment. Anything received for a referral is over and above this fee.
Let’s move on then to the referral itself, we have:
1 x Piece of A4 Paper on which to write referral, cost: £0.01 (You can get 500 sheets for £5 from our local WH Smith)
1 x Biro to write letter, cost: £0.49 (Good old WH Smith again)
5 minutes of Secretary’s time to retrieve details and write them out, cost: negligible (the secretary is employed full time anyway like I said).
1 x local stamp, cost: £0.37
Total cost of referral to Hospital = 0.87.
If we do our Maths, the markup is over 3488%, more if you take into account the fact that £30 is only an approximate figure but still I’m sure that not every Doctor is responsible.
After all if a Doctor only made 10 referrals every month, they’d only be able to salt away a meagre £300 extra a month on top of consultation fees. My heart bleeds.
V.
Report abuse
The cost of buildings, secretaries, electricity and IT is not irrelevant. If an additional charge were not levied to cover the costs of a referal consultation fees would have to rise to cover these costs, this is hardly fair for those patients who do not require referal. Equally the time taken for a secretary to produce a letter is not five minutes, it is an important clinical and legal doccument that is not just hashed together in five minutes. If GPs did not make referals they would not require a secretary. The cost of producing a referal is £30. We have a competitive market in Jersey, if GPs charge over and above the odds patients will move elsewhere. GPs in Jersey do not receive a salary from the state.
Report abuse
Dear House,
Well said!
Report abuse
Well naturally to the GP concerned these costs are not irrelevant but in light of the topic of discussion they are.
Let us imagine that next month a local GP sees patients as normal and makes no referrals. The Doctor in question receives around £30 per consultation (far more for home visits) and of course a handsome commission on prescription medication but let’s not go into that.
Out of this comes their salary, that of their secretary and the costs of running the surgery. This includes a medical secretary who is employed 9-5, five days a week regardless. If the Doctor then asks him or her to print off a tweaked generic referral letter to sign the following month, how has this increased expenses beyond the ink/paper/stamp I have already costed?
I find it astonishing that you say that a secretary is only needed for referrals – how else would they arrange appointments, home visits and send samples to the hospital? What about taking payments for consultations and updating and storing patients’ files?
As for patients not liking Doctors’ fees, they would seem to have little choice in Jersey. A few well meaning GPs run free clinics but elsewhere if you want to see a Doctor you have to pay. This as I said is in addition to the fee charged from the public coffers for the supposed referral, perhaps any GPs reading this might like to provide an costed breakdown of the £30? I’m not optimistic.
V.
Report abuse
Just to clinch the debate, at the hotel where I work, an out of hours GP called today to see one of our guests who had hurt his back. He called him an ambulance and wrote the referral letter in his car. It took him 30 minutes – I told him about the situation in Jersey and he told me it was laughable – the costs of doing a referral are pennies not pounds he told me, as he gave me the letter to pass onto the ambulance. (I suppose that in so doing he saved himself the cost of a stamp).
There’s a word for when someone charges an excessive fee for a service, which is extortion. If any GP feels aggrieved by me using this word they’re welcome to provide a costed breakdown of the £30 mentioned to justify the price. Don’t hold your breath…
V.
Report abuse
x 3.
All this talk about overheads!
Most GPs share premises, running costs and a secretary. They see and average of 30 patients per day, which works out at almost £1000 per day (5 days per week x 48 weeks per year, plus call outs, etc., not bad eh!). Therefore, why should they be paid for referring a patient to the hospital when they have already been paid by the patient?
In these ‘hard times’, the States (taxpayer)should put an end to payment for this pseudo-service, as it’s already part of the patient-GP package. Furthermore, if there is no gain to be had from referrals, it will put an end to this more-than-suspect praxis.
Report abuse