The agony around advice and guidance

NHS England is reportedly considering limiting GPs’ scope to make direct referrals. Eliza Parr looks at the potential consequences for practices and patients

Next month, NHS England is due to release its new outpatients strategy. It could have a seismic effect on general practice. 

It is likely to expand the use of advice and guidance (A&G), reportedly making it mandatory in some cases. GPs may be asked to significantly reduce their direct referrals to secondary care. 

A&G has been creeping in for the past decade in England, with a number of trusts asking GPs to use this route in the first instance. Pathways vary locally, with A&G used for most specialties in some areas but just one or two in others. 

For now A&G has not completely replaced the right to refer, and some GPs find it a helpful mode of dialogue with their consultant colleagues.

But others have experienced an increase in workload, finding they retain clinical responsibility for patients they may not feel comfortable with. This, of course, brings medicolegal implications. And even A&G’s biggest GP supporters warn that mandating its use will have grave effects. 

It may be that NHS England’s plans will be a moot point. Because GPs are reporting that it is already de facto becoming compulsory, with referrals being sent back with advice and guidance even when GPs insist on a consultation.

How has A&G worked in practice?
The availability of A&G has grown, and incentives have been added (see Box 1). E-requests for specialist advice across England have increased by around 60% over the past two years. NHS England’s specialist advice activity dashboard, which tracks A&G requests made via e-RS, shows an increase from 140,000 requests per month in Q3 2021, to almost 210,000 in July this year¹ (see graphs). 

While many GPs do find it a helpful way to liaise with consultant colleagues when unsure of the next steps for a patient, there has been no shortage of pushback or concerns, locally and nationally. 

In Nottingham last year, a trust introduced a new virtual neurology triage system that led to a huge increase in referrals being rejected or returned to the GP with advice. Dr Irfan Malik, who campaigned against its introduction, says: ‘If we want advice and guidance, and that’s what we have requested from the consultant, then most of the time it works quite well. But if we hadn’t requested it, and we just get advice back, that’s where we get the issues. And sometimes it creates more work for us.’ This extra work, Dr Malik points out, is unfunded in general practice. In contrast, consultants are funded to complete A&G requests as part of their job plan. 

According to NHS England’s dashboard, the North East and Yorkshire region has consistently had the highest ‘diversion rate’ – the percentage of A&G requests that avoid a referral (see table, below). ‘I think it’s been mandated for us for a while, it sort of gradually crept in, and then kind of escalated throughout Covid,’ says Dr Pipin Singh, a GP partner and training programme director in North Tyneside. ‘Now it is pretty much part of the norm with most specialities. So we’re all using it very regularly.

‘It puts pressure back on us because we might have to generate another appointment to speak to a patient about what the plan is. There may be a series of scans or a load of tests that the trust would want us to do before referring, adding extra pressure on our admin teams.’

One specialty where A&G is closest to being compulsory is dermatology. A year ago, NHS England suggested this should be its main referral pathway, and many GPs now say they have to send dermatoscope images before a referral is accepted. 

This process is not without positives. Walsall LMC medical secretary and GPC member Dr Uzma Ahmad says dermatology is one area where seeking advice first is useful, because it saves waiting for the patient and ‘from a learning point of view’ for the GP. It’s the same in east London, where Tower Hamlets GP Dr Selvaseelan Selvarajah says the dermatology pathway is working especially well. 

However, one issue that blights dermatology A&G – and is likely to be seen in other specialties – is the time taken for consultants to respond.

Dr Selvarajah says: ‘Because of massive delays in secondary care, we’re now noticing that advice and referrals aren’t coming back on time. The timelines we agreed to with specialities aren’t always adhered to so it can take a while for responses to come back. 

‘Dermatology used to be within a week, now it’s taking two to three weeks, if not longer.’ 

In Tower Hamlets, the LMC has successfully lobbied for funding from the ICB for the extra work for GPs, amounting to around £19 per episode. But despite co-designing a version of A&G for general practice, Dr Selvarajah says hospital backlogs leave him fielding around 10 extra queries a day from patients who find the situation ‘challenging’.  

‘[Queries from patients are] massively increasing because of the waiting lists in hospitals, both for advice or referral and traditional appointments,’ he says. ‘It’s all combined into one, and that’s actually putting a lot of pressure on primary care.’

What will a wider rollout of A&G mean?
While many GPs acknowledge the benefits of advice and guidance when it works well, they’ve been unequivocally opposed to a nationally mandated system. Two years ago, the England LMCs conference voted unanimously for the BMA’s GP Committee to ensure GPs cannot be required by commissioners or providers to use A&G.

Indeed, Nottinghamshire LMC chair Dr Carter Singh believes such a move could result in many GPs leaving the profession. ‘Advice and guidance needs to be used in the appropriate settings and it can work well,’ Dr Singh says. ‘But if there’s any hint of mandating it, I think that is the day when the clinical autonomy and the decision-making processes of GPs will be reduced to nil.’ 

In Derbyshire, LMC treasurer and GPC member Dr Peter Holden says this is a ‘political thing… it’s there to make the waiting lists look good’. He has long raised concerns with his local trust and believes A&G is ‘just another Berlin Wall being put up to prevent [GPs] referring’. 

There are psychological, medicolegal and contractual issues around a wider rollout of A&G. 

The psychological aspects extend to both GPs and patients. County Durham GP Dr Kamal Sidhu says: ‘It causes lot of dissatisfaction for patients and clinicians alike. We are no longer able to assure our patient that they have been referred to secondary care and will be seen by a hospital specialist.’

The failure to refer is one of the biggest reasons for patient complaints, and an expansion of the scheme will exacerbate this. Dr Singh says that when A&G is used instead of referrals ‘it’s going to be the GP who’ll be labelled as the bad cop in that whole situation’. He adds: ‘Patients can actually put a face to the name of the GP. That’s where the complaint ends up – on the GP’s desk.’

There is another psychological aspect. At a time of stress and burnout, referrals can be a release valve for GPs, allowing them to divert responsibility, for a while at least. 

GP partner in Surrey Dr Dave Triska says: ‘If I do a letter to refer someone for a face-to-face appointment, that whole process is going to take a minute or two. For advice and guidance, I might be committing six hours of my time getting a response, calling the patient in. That’s an enormous difference.’

A key worry is the medicolegal aspect (see Box 2).  An issue that hasn’t been discussed much is the need for the GP to provide a more detailed assessment in the A&G communication, as specialists may not be seeing the patient themselves. 

Dr Sidhu says: ‘Secondary care can only make a decision based on the information you provide. That means you need to provide more detailed history and sometimes it is not possible to capture the information in a clinical letter, alongside the workload implications these bring.’ 

Finally, there are contractual implications. As part of the contract, GPs have a duty to refer and it is unclear what will happen if a referral is refused. 

Dr Triska adds: ‘The GP contract does not cover providing outpatient services but A&G is being utilised as a grey mechanism to allow that contract to be bent as far as it will possibly go.’

GPs are not alone in warning about any expansion of the scheme. In March, MPs from the Commons Public Accounts Committee said A&G ‘has potential’ but there is so far ‘limited evidence of effectiveness’. Meanwhile, a Health Foundation-funded report from the Institute for Government and Public First concluded: ‘It is possible expanding A&G further could help reduce the backlog and the pressure on hospitals but it is also possible that this combined with rejected or failed referrals is storing up bigger problems for the future.’²

A&G a firm part of NHSE plans
But whether GPs like it or not, advice and guidance seems here to stay. The NHS operational planning guidance for 2023/24 cites its use as means to deliver 30% more elective activity by next year.³ And in August, NHS England wrote to trusts asking them to ensure they have plans to expand the use of specialist advice. In fact, the letter said many systems are already delivering 21 A&G requests per 100 referrals, exceeding the national target of 16.

In September NHS England confirmed it was working on an outpatients strategy in partnership with the Royal College of Physicians (RCP). The Health Service Journal reported this could include a move to replace most direct referrals with A&G.⁴ NHS England says no final decisions have yet been made but RCP outpatients lead Dr Theresa Barnes, who is part of the working group, has called for a ‘push’ to use A&G ‘in preference to direct referrals’.

The RCGP, the National Association of Primary Care and representatives from NHS England’s primary care team have all been involved as stakeholders. An RCP spokesperson said the group is taking a ‘patient-focused approach’, which includes encouraging ‘shared decision making between primary and secondary care to support care being delivered in the most appropriate setting’.

‘Key to that is making sure that GPs are able to access timely specialist advice to make sure patients receive the care they need as quickly as possible,’ the spokesperson added.

However, the RCGP is concerned about increased use of A&G, saying that in some areas it has been used as a ‘barrier to artificially protect waiting lists’. 

And those waiting lists continue to rise. The latest NHS data show a record 7.75 million people waiting to start treatment at the end of August. Some 400,000 of those patients have waited more than a year. With huge pressure building on secondary care, it seems probable that NHS England’s imminent outpatients plan will look to ease this pressure via the A&G pathway.  

But whether it does so or not, the unofficial use of A&G – with referrals rejected in favour of advice and guidance – risks become the norm. 

In the West Midlands, Dr Ahmad says her trust has implemented a referral assessment service for some specialties over the past couple of years. While this is not technically an A&G pathway, she says it still results in rejected referrals. 

‘They will just say they either reject the referral or they will say do this, this and that,’ Dr Ahmad says. ‘And I have not even asked for advice and guidance, I need a proper referral and they don’t value that at all. They just think they can reject or give advice, and it is not an A&G pathway.’

And as long as NHS waiting lists continue to rise, the responsibility to reduce them looks set to fall increasingly on the shoulders of GPs, regardless of the impact on their workload or on patient care. 

References

1.  NHS e-Referral Service (e-RS) open data dashboard. Link
2.  Institute for Government and Public First. The NHS productivity puzzle. June 2023. Link
3.  NHS. 2023/24 priorities and operational planning guidance. January 2023. Link
4.  Illman J. Direct GP referrals may cease for many non-urgent cases under new national strategy. HSJ. 20 September 2023. Link