The desperate British medical bureaucracy

Family doctors paid bonuses to NOT send you to hospital. It could cause you to have an avoidable amputation but who cares?

GPs are to be paid cash bonuses in return for not sending patients to hospital, raising concerns that financial gain will be put before patients' needs. Doctors' practices stand to earn thousands of pounds extra under the initiative, already said to have been adopted by health authorities across the country. In a variety of schemes, which differ from region to region, GPs are said to have been offered unprecedented cash incentives for deciding not to refer a patient for specialist treatment. Surgeries are given a target of how many patients they should refer to hospital each year and will receive a windfall payment if they meet the quota. Conversely, the money is lost if the surgery sends more patients to hospital than allowed for under the health authority target.

The Mail on Sunday has established that in Oxfordshire each surgery will be given a target of how many patients it should refer to hospital every year. If it meets those quotas, it will be eligible for a bonus payment of up to $20,000. GPs in the region will be paid a similar amount to set aside additional time to review decisions on whether patients should be given hospital appointments. It was reported last night that under another local scheme, doctors in Torbay in Devon could make $120 for every patient not referred. Practices in London, Essex and Wiltshire were said to be in line for $9 for every patient on their list if they meet targets which include a curb on the number of referrals.

The bonus money will be paid into the coffers of GPs' practices, from which they draw their income, giving clinicians for the first time a direct financial incentive to refuse further treatment to patients.

The initiative will cause deep unease, even among doctors who could profit from it. Commenting on the Oxfordshire scheme, Dr Laurence Buckman, chairman of the British Medical Association's GP Committee, told The Mail on Sunday it was `morally dubious, ethically disturbing and quite wrong'.

The schemes are seen as an attempt by NHS managers to direct patients away from the overloaded hospital system towards cheaper health workers, such as physiotherapists. But Stephen Cannon, a consultant surgeon at the Royal National Orthopaedic Hospital, said last night that potentially fatal tumours had already gone undiagnosed because of the scheme.

He said: `I recently encountered two cases in which patients referred to physiotherapists later turned out to have a malignant tumour. In one, a young man was referred to a physiotherapist because of sudden knee pain. Had he come to a specialist the symptoms should have been recognised and he should have been urgently referred to an oncologist. In this case, after the delays, the outcome was amputation. It was devastating for the patient and his family.' ....

Dr Buckman said: `The idea that we should pay doctors to behave in a particular way is worrying. There is a huge difference between paying GPs to increase vaccination levels - which is public health policy and therefore perfectly reasonable - and rewarding them for not referring a patient. `Many patients are referred for further investigation rather than treatment and it would be incredibly dangerous if these patients failed to get hospital appointments simply because GPs decided they weren't sure if a referral was strictly necessary. `The reason for a rise in referrals is very complicated and this isn't the way to deal with it. We should be trying to understand the reason for the referrals.'

Oxfordshire Primary Care Trust insisted it is not paying GPs not to refer but to review their practices, and that every patient who needs to be referred to hospital will get an appointment. Alan Webb, director of commissioning, said the Trust hoped the savings made would go back into patient care.

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Australian public hospital doctors 'tired and dangerous'

This appalling system has been going on for ages. No-one seems willing to stop it -- on cost grounds presumably

Overworked young doctors are close to burn-out from working 20-hour shifts and are getting less than six hours sleep a night. Patients' lives are being put in "danger", with stressed young doctors confessing their "unsafe" workloads were affecting their quality of medical care. These were two key findings in a national survey of 1000 young doctors by the Australian Medical Association released yesterday.

It paints a distressing picture of junior medical staff trying to cope in hospital systems that are underfunded and understaffed. Almost half believe their excessive workload runs the risk of compromising patient safety, while a third reported they regularly worked unsafe hours. Fifty hours a week is common with short turnaround times between shifts, while some said 90 to 100-hour weeks were not uncommon. Alcohol was another worrying method young doctors were using to cope with stress and fatigue, with the survey finding almost 10 per cent drank daily.

Sydney's Westmead Hospital intensive care resident Katherine Jeffrey, who confessed to working 60 hours a week, said more younger doctors were urgently need to improve quality care and prevent patient tragedies. "There is a danger of mistakes if you don't monitor yourself and if you don't get the sleep," said the 35-year-old critical care resident, who lives at Cheltenham. "Generally most of us are doing 50-60 hours a week which also included rostered overtime."

Dr Jeffrey, who said she sailed to ease her stress, said sleep-deprived young doctors, aged between 26 and 35, were also taking out their frustration on other medical staff. "They are short with the nurses, they're short with the patients - they are intolerant of little things." Dr Jeffrey confessed to once being awake for a 21-hour shift, which was "rare", due to a doctor shortage. "I could feel that I was fatigued."

AMA Doctors In Training Council chairwoman Dr Alex Markwell said it wasn't unusual for young doctors to be on call 24 hours a day for three weeks straight. "We do need urgent assistance in the public health system," she said. Dr Markwell said the survey showed junior doctors were "really struggling to meet all of the demands that are put upon them. Doctors are people too, they are not superhuman," she said. Dr Markwell suggested establishing an internal clinic for medical staff inside hospitals.

AMA president Dr Rosanna Capolingua said the problem must be addressed by governments by having more doctors in hospitals, safer working hours and better rostering.

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