CORRESPONDENCE * All letters must be typed with double spacing and signed bv all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ3. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Too much to swallow SIR,-The family health services authority has sent me an abstract of the list of tariffs for extracontractual referral for 1991-2 published by the regional health authority.' The table shows the tariffs for some of the endoscopic procedures and for a barium meal investigation in three city hospitals (hospitals 1-3) and an adjacent peripheral district general hospital (hospital 4). One of the city hospitals even differentiates between direct referral to the endoscopy clinic and indirect referral. The hospital authorities and doctors need to address the disparity in the charges as it has serious financial, clinical, organisational, and medicolegal implications. Hospital 4 should prepare to make contingencies in the event of all practitioners in the city persuading their health authority to seek contracts for an endoscopy service with it. Hospitals 3 and 4 need to reassure the public and general practitioners that the low cost of their assessment procedures is no reflection of the standard of their service compared with that of hospitals with charges five to 10 times more. Hospitals 1 and 2 need not only to justify their high costs but to claim, for example, that the quality of their care is better or the waiting list shorter. Barium meal examination is offered by only one of the city hospitals and the peripheral hospital. The tariffs seem reasonable. Investigating an upper gastrointestinal lesion by both barium meal examination and endoscopy, however, would have considerable implications with regard to cost. I will not be surprised if in future health authorities consider it to be financially justifiable to suggest assessing patients with dyspepsia by the considerably cheaper, though less accurate, barium meal examination and restricting endoscopy for those in whom the results ofsuch examinations are negative. Endoscopic assessment in the city may decrease, with a possible erosion in the uniformity of standards. General practitioners cannot obtain cost effective and clinically desirable endoscopic assessment from the neighbouring hospitals owing to limitations on referrals imposed by the district health authority. Such a disparity in tariffs and threatened erosion
of the range and quality of service is a sad reflection of our ability to comprehend the needs of the community and the profession. The BMA has worked with general practitioners to introduce a standard fee for all items of service irrespective of the skill of the practitioners, building costs of premises, and organisational costs. Is it too difficult for hospitals to emulate this? To preserve our clinical practice, to prevent fragmentation of services, and to maintain our professional image and integrity let us coordinate our plan to standardise our service and costs. It will enable us to offer the quality of care that patients deserve. S J JACHUCK Medical Research Centre, Newcastle upon Tyne NES 2LH 1 Northern Regional Health Atithoritv. Tariffs for extracontractu4al referral 1991/92. Newcastle upon Tvne: Northern Regional Health Authorits, 1991.
Nightmare of extracontractual referral SIR,-Extracontractual referrals are in danger of becoming an issue out of proportion to their real importance.' They are an impediment to the effective treatment of patients created by the reforms. There is a high probability that the net flow of funds caused by extracontractual referrals over a reasonable interval will be negligible. Insurance companies recognise a comparable effect with claims related to vehicles, and few organisations can claim to be more parsimonious than they. The "knock for knock" arrangement which insurance companies find so attractive commends itself for obviating the question of extracontractual referrals. Recent correspondence with a new fangled medium grade panjandrum suggested that such a decision lay outwith her purview and rested with a much more Olympian panjandrum. Happily there was, implicit in the correspondence, recognition of the rightness of the extracontractual referral in question and the suggestion that substitution of
Costs (£) of various procedures in three city hospitals (1-3) and peripheral district general hospital (4)
Oesophagoscopy with or without endoscopic procedures Endoscopv with or without endoscopic procedures Barium meal examination
*Direct referral. tother. ERCP=endoscopic retrograde cholangiopancreatography.
360
Hospital 1
Hospital 2
Hospital 3
1840
916
897
1580
555* 820t 324* 920t
56
Hospital 4
addresses would neatly circumvent the problem. I am entirely content to "perjure" myself for a patient's benefit and commend the ruse to the profession at large until such time as the Department of Health restores sanity to the situation. STEVEN FORD Haydon Bridge, Northtimberland NE47 lHJ I Jonies PM\. Nightmare of extracontractual referral. B.MJ 1991;303:59. (6 July.)
SIR,-Increased documentation since the NHS and Community Care Act 1990 was implemented is reflected in many transactions in the health service, extracontractual referrals being one such example.' These referrals and associated subsequent treatment are not governed by contracts between purchasing authorities and provider units. After one of its residents has been treated by a provider unit a purchasing authority is therefore charged on a cost per case basis. As extracontractual referrals can be costly they are closely monitored by purchasing authorities, and ours in South Tees is no exception. Such monitoring is resource intensive but is considered to be necessary for financial reasons. There is another reason for continuing with this exercise, as the following case illustrates. A 29 year old man presented to 12 different hospitals in England and Wales with symptoms of abdominal pain or of deliberate self harm between April and June 1991. On each occasion he used the same name and address, which identified him as a resident of South Tees Health District. From his illness behaviour we suspected Munchausen's syndrome and have notified other health districts, through the regional medical officers, of the patient's details. The bill for his health care totalled £12 000. This case came to light because of the patient's consistent use of the same name and address and because extracontractual referrals were being monitored. The patient may eventually have come to the notice of health authorities anywav, but monitoring possibly speeded up the process. The case has helped to revive flagging interest (on the part of public health physicians) in the exercise of monitoring extracontractual referrals as we debate whether, having notified other health authorities of the patient's details, we should pay up the next time a provider unit bills us on his behalf. RAJAN MADHOK IAN HOLTBY
483
166 (gastroscopy) 333 (ERCP) 40 76
South Tees Public Health Directorate, Poole Hospital, Middlesbrough, Cleveland TS7 ONJ I Jones P'M. Nightmare of extracotntractual rcferral. B'.JIM 1991;303:59. (6 J uly.)
BMJ VOLUME 303
10 AUGUST 1991
Too much to swallow SIR,-The family health services authority has sent me an abstract of the list of tariffs for extracontractual referral for 1991-2 published by the regional health authority.' The table shows the tariffs for some of the endoscopic procedures and for a barium meal investigation in three city hospitals (hospitals 1-3) and an adjacent peripheral district general hospital (hospital 4). One of the city hospitals even differentiates between direct referral to the endoscopy clinic and indirect referral. The hospital authorities and doctors need to address the disparity in the charges as it has serious financial, clinical, organisational, and medicolegal implications. Hospital 4 should prepare to make contingencies in the event of all practitioners in the city persuading their health authority to seek contracts for an endoscopy service with it. Hospitals 3 and 4 need to reassure the public and general practitioners that the low cost of their assessment procedures is no reflection of the standard of their service compared with that of hospitals with charges five to 10 times more. Hospitals 1 and 2 need not only to justify their high costs but to claim, for example, that the quality of their care is better or the waiting list shorter. Barium meal examination is offered by only one of the city hospitals and the peripheral hospital. The tariffs seem reasonable. Investigating an upper gastrointestinal lesion by both barium meal examination and endoscopy, however, would have considerable implications with regard to cost. I will not be surprised if in future health authorities consider it to be financially justifiable to suggest assessing patients with dyspepsia by the considerably cheaper, though less accurate, barium meal examination and restricting endoscopy for those in whom the results ofsuch examinations are negative. Endoscopic assessment in the city may decrease, with a possible erosion in the uniformity of standards. General practitioners cannot obtain cost effective and clinically desirable endoscopic assessment from the neighbouring hospitals owing to limitations on referrals imposed by the district health authority. Such a disparity in tariffs and threatened erosion
of the range and quality of service is a sad reflection of our ability to comprehend the needs of the community and the profession. The BMA has worked with general practitioners to introduce a standard fee for all items of service irrespective of the skill of the practitioners, building costs of premises, and organisational costs. Is it too difficult for hospitals to emulate this? To preserve our clinical practice, to prevent fragmentation of services, and to maintain our professional image and integrity let us coordinate our plan to standardise our service and costs. It will enable us to offer the quality of care that patients deserve. S J JACHUCK Medical Research Centre, Newcastle upon Tyne NES 2LH 1 Northern Regional Health Atithoritv. Tariffs for extracontractu4al referral 1991/92. Newcastle upon Tvne: Northern Regional Health Authorits, 1991.
Nightmare of extracontractual referral SIR,-Extracontractual referrals are in danger of becoming an issue out of proportion to their real importance.' They are an impediment to the effective treatment of patients created by the reforms. There is a high probability that the net flow of funds caused by extracontractual referrals over a reasonable interval will be negligible. Insurance companies recognise a comparable effect with claims related to vehicles, and few organisations can claim to be more parsimonious than they. The "knock for knock" arrangement which insurance companies find so attractive commends itself for obviating the question of extracontractual referrals. Recent correspondence with a new fangled medium grade panjandrum suggested that such a decision lay outwith her purview and rested with a much more Olympian panjandrum. Happily there was, implicit in the correspondence, recognition of the rightness of the extracontractual referral in question and the suggestion that substitution of
Costs (£) of various procedures in three city hospitals (1-3) and peripheral district general hospital (4)
Oesophagoscopy with or without endoscopic procedures Endoscopv with or without endoscopic procedures Barium meal examination
*Direct referral. tother. ERCP=endoscopic retrograde cholangiopancreatography.
360
Hospital 1
Hospital 2
Hospital 3
1840
916
897
1580
555* 820t 324* 920t
56
Hospital 4
addresses would neatly circumvent the problem. I am entirely content to "perjure" myself for a patient's benefit and commend the ruse to the profession at large until such time as the Department of Health restores sanity to the situation. STEVEN FORD Haydon Bridge, Northtimberland NE47 lHJ I Jonies PM\. Nightmare of extracontractual referral. B.MJ 1991;303:59. (6 July.)
SIR,-Increased documentation since the NHS and Community Care Act 1990 was implemented is reflected in many transactions in the health service, extracontractual referrals being one such example.' These referrals and associated subsequent treatment are not governed by contracts between purchasing authorities and provider units. After one of its residents has been treated by a provider unit a purchasing authority is therefore charged on a cost per case basis. As extracontractual referrals can be costly they are closely monitored by purchasing authorities, and ours in South Tees is no exception. Such monitoring is resource intensive but is considered to be necessary for financial reasons. There is another reason for continuing with this exercise, as the following case illustrates. A 29 year old man presented to 12 different hospitals in England and Wales with symptoms of abdominal pain or of deliberate self harm between April and June 1991. On each occasion he used the same name and address, which identified him as a resident of South Tees Health District. From his illness behaviour we suspected Munchausen's syndrome and have notified other health districts, through the regional medical officers, of the patient's details. The bill for his health care totalled £12 000. This case came to light because of the patient's consistent use of the same name and address and because extracontractual referrals were being monitored. The patient may eventually have come to the notice of health authorities anywav, but monitoring possibly speeded up the process. The case has helped to revive flagging interest (on the part of public health physicians) in the exercise of monitoring extracontractual referrals as we debate whether, having notified other health authorities of the patient's details, we should pay up the next time a provider unit bills us on his behalf. RAJAN MADHOK IAN HOLTBY
483
166 (gastroscopy) 333 (ERCP) 40 76
South Tees Public Health Directorate, Poole Hospital, Middlesbrough, Cleveland TS7 ONJ I Jones P'M. Nightmare of extracotntractual rcferral. B'.JIM 1991;303:59. (6 J uly.)
BMJ VOLUME 303
10 AUGUST 1991
