Good day to you.

A quick browse of The Economist's poll on whom global Economist readers around the world would like to be next president of the USA has found cold comfort for the Grand Old Party's candidates Senator John McCain and his deputy governor Sarah Palin. The McCain / Palin ticket is ahead in just six countries: in five of these - Algeria, Democratic Republic of Congo, Cuba, Macedonia and Sudan - they have a lead over Democrat cadidate senator Barrack Obama and his deputy Senator Joseph Biden. And in which nation do the Republicans have a 'strong' lead?

Um, Iraq.

From the global to the local, then - the rise in GP referrals to secondary care (discussed with NHS Alliance chair Dr Michael Dixon in our recent interview) has continued.

This presents obvious financial and logistical issues for PCTs and trusts trying to maintain their progress or success (depending whose figures you prefer) on the 18 week referral to treatment target. As a result, some PCTs have brought in incentive payments to GPs to address - i.e. reduce - their referral patterns

The DH has written to all SHAs on 24th October, saying that where incentive schemes are in place, PCTs should ensure that: “they do not in any way undermine – or be constructed in a way that could be perceived as undermining – the GP’s overriding clinical and professional duty to provide the best care for each individual patient”.

Conflicts of interest
Current GMC rules state that doctors must not accept or offer any inducement that might affect – or be seen to affect – the way they treat or refer their patients. Conflicts of Interest, GMC rule 74 says, “you must act in your patients’ best interests when making referrals and when providing or arranging treatment or care. You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients. You must not offer such inducements to colleagues”.

Now the NHS Alliance has called for the GMC to rule on precise circumstances in which the incentive payments some PCTs offer GPs would be permissible - or not. NHS Alliance have suggested in a statement that the GMC policy “appears to mean it is acceptable to pay incentives to GPs to review the way they refer.

"Regular review is good practice: it can highlight any issues about low referrals as well as high, educate doctors about possible alternatives to hospital treatment, and improve medical practice. But any doctor who accepted a payment to cut the numbers of referrals, or not to refer, might be acting wrongly”.

Director of the NHS Alliance Practice-Based Commissioning (PBC) Federation Dr David Jenner has said, “we don’t believe that doctors’ decisions to refer are being influenced by incentive payments. That would clearly be wrong and in breach of the rules. However, the rules aren’t just about accepting inducements. Doctors should not give the appearance of acting in a way that isn’t in the patient’s best interests.

“These new schemes seem to be in a grey area that has never been considered before. It is only the GMC who can issue professional guidance and they should do so immediately – not only for the sake of patients and their GPs, but also for PCT medical directors who could be accused of offering inducements.”

The NHS Alliance are not suggesting that PCTs are applying direct pressure to encourage doctors not to refer when it is clinically appropriate to do so. They also note that it is entirely appropriate - and indeed good practice - for individual and peer review of referral partterns and rates.

Furthermore, they are welcoming the clarification from the DH to SHAs around this matter. Almost all incentives have unintended consequences as well, and the huge political priority resting on 18 weeks adds in another dynamic that may not be entirely helpful.