Yes: Dr Peter Moore A GP at the Chilcote Surgery, Torquay

I find it highly offensive that people would suggest that I would not send a patient to hospital for financial gain. As a doctor, you put your patients' needs first.

Torbay and Devon Primary Care Trusts are looking at introducing incentives and I believe it is a very innovative idea. Over the past five years there has been a substantial increase in hospital admissions. Some are obviously necessary — if somebody is seriously ill there is no question that we would not refer them.

The problem is there are a lot of patients who are referred unnecessarily. You may get someone who is not coping but does not have an acute medical problem. We can often provide a better service by keeping them at home.

We also want to prevent admissions by stopping people becoming ill. The UK is fortunate in having excellent primary care in general practice and we prevent a lot of unnecessary hospital work. By doing investigations and working with social services, GPs can help keep hospitals free for really ill people who need surgery or intensive care that you cannot do outside.

In our practice, we have a link with the Met Office, which sends us a copy of the weather reports, so we can monitor when patients with certain chest conditions need to take antibiotics, for example. That has dramatically reduced our admissions and we have much better control of our patients.

But preventing admissions requires extra work on our part, paying specialist nurses, for example. If we are going to do this, all we are talking about with payment for reducing referrals is payment for work done. GPs are self-employed, we run our own businesses and employ our own staff. Therefore, if we increase nurse hours, it has to be paid for. In a system with no incentives, the doctors who are conscientious and try to keep people at home would have to employ more staff, do more work. So they would lose money for doing more work than the GPs who send everyone to hospital.

One of the commonest reasons for complaints against doctors, even court cases, is failure to refer. General Medical Council (GMC) guidelines state that we must ask another colleague if we are unsure of whether to refer someone. If we do not refer we are taking a risk of ending up in front of the GMC or in court, so there is no way we would not refer if appropriate.

Junior doctors often over-refer patients. As a GP, you gather the evidence and examine people and make a judgment. A junior doctor may not have the experience to decide or may not be aware of social service options. We can get an older person into a nursing home for a few days if they have a fall, for example. It's better for the patient — nobody likes going to a general hospital. Incentives help people think about the alternatives.

Hospital referrals are going up. The healthcare system does not have unlimited resources and money spent on unnecessary admissions is not there to be spent on something else.

No: Professor Martin Roland, Director, National Primary Care Research and Development Centre

The simple answer is no. Oxfordshire Primary Care Trust (PCT) is faced with the budgetary pressure of a year-on-year rise in the number of referrals. The PCT has introduced a scheme of paying GPs to reduce the number of patients they refer to hospital. History suggests that a blunt instrument like this may be effective — but some patients will suffer by not being referred when they should have been.

To be fair, the scheme is more sophisticated than that. The PCT is also offering an incentive for GPs to discuss patients with other GPs in their practice before they actually make a referral. This is one of the advantages of being in a group practice and some research suggests this is a good idea.

A controlled trial in Wales found that when GPs discussed potential referrals with colleagues in their practice, a substantial number could be avoided without loss of patient satisfaction. In Oxfordshire, providing an incentive for GPs to look critically at their referrals is to be applauded. As GPs are self-employed, this essentially means providing more time for them to carry out these reviews.

The PCT needs to be careful not just to focus on numbers of patients referred. It is no surprise that GPs are referring more patients to specialists. The referral system has become a victim of its own success. The past few years have seen a dramatic reduction in waiting times and an increase in the number of consultants and “GPs with a special interest”. The amount of specialist care available has increased and, not surprisingly, demand for it has increased.

The PCT needs to find out if patients who are referred actually benefit from those referrals. Suppose they look at the appropriateness of referrals and find that most patients benefit from seeing a specialist. Then the public should have serious doubts about the new incentive scheme. We know that some doctors with more advanced knowledge in a clinical area actually refer more patients. This is because they know about the specialist care from which their patients could benefit. There may also be GPs who lack confidence in a particular area and refer more patients with those sorts of problem. Would patients really want those doctors to have a financial incentive not to refer them to a specialist? I don't think so.

Financial incentives always have the potential to produce unintended effects. An example in 2004 was the introduction of an incentive for GPs to give their patients appointments within 48 hours. The way that was implemented meant that patients found it harder to book ahead. It was a clear example of a good idea that produced an unintended negative consequence.

So Oxfordshire PCT needs to recognise that there are risks to patients if they give financial incentives to GPs to reduce referrals. This will not automatically improve quality of care or lead to better use of resources. Finding ways to help GPs to look more critically at their referrals may do.

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