NHS England has set targets to reduce referrals, but GPs are warning this could hit their workload, says Rachel Carter
‘Advice and guidance’ (A&G) has been around since 2015, when the choose and book service was revamped with the introduction of electronic referrals. Even before then, it existed in various formats.
But with the Covid-19 pandemic seeing more patients diverted away from hospitals, and rocketing waiting lists, it could become a major part of GPs’ lives.
Some see benefits in the greater use of A&G. Indeed, Pulse’s campaign to ‘Build a Better General Practice’ earlier this year found timely and accessible advice from secondary care – which is the definition of A&G – was absolutely essential.
Recent developments, though, signal that A&G is moving away from being an optional service for GPs and is about to become central to government plans to address the elective surgery backlog.
Far from being a good news story, it seems the advice will come with targets attached, including for cutting referrals.
October saw the introduction of a target on A&G referrals for the first time. In its planning guidance for the second half of 2021/22, NHS England mandated a minimum of 12 A&G requests per 100 outpatient attendances by March 2022.
The guidance says all systems will have to ‘demonstrate monthly increases in referral optimisation, with assessment to monitor the impact on avoiding referrals and on improving patient experience and outcomes’. However, NHS England provided no further detail on how the target could be mandated.
Now a CCG and a hospital trust, both in London, have separately set out plans to cut GP referrals via A&G, by numbers that go beyond the NHS England target.
NHS North Central London CCG is proposing to reduce GP referrals across seven hospital trusts by 65%, according to a service specification seen by Pulse. Meanwhile, Barts Health NHS Trust, in east London, has launched a trial spanning 13 specialties that requires GPs to use A&G before referring patients. The trust says the approach ‘could become the default for all services’ if successful.
The problem with such an approach is that when a patient is referred, the responsibility is taken on by secondary care. But under the A&G schemes currently being pushed, this responsibility stays with general practice – which is already facing unsustainable workloads – and brings in medicolegal issues around GPs retaining clinical responsibility for a patient even if they had judged referral to be the best option.
GP Survival chair Dr John Hughes says it is ‘completely inappropriate’ to have targets for any type of referral because ‘it completely ignores the fact that what is referred, and how, depends on the patient, their demographics, the presentation and to some extent what facilities are available locally’.
He says: ‘It’s completely inappropriate and micro-management of the GP’s clinical decision to refer. It’s also a potential breach of the GMS contract, which states the GP treats in the manner decided by the practice in discussion with the patient.
‘As I see it, it’s NHS England breaching their own contract to try to impose criteria on GPs as to how they handle referrals.’
Research carried out last year by the North of England Commissioning Support (NECS) on behalf of NHS England concluded that A&G represents a ‘significant time and resource challenge to primary care’ and that general practice staff ‘do not have additional time to follow up A&G actions’.
What the NECS research found
NHS England commissioned NECS to carry out research on the demand side of A&G in 2020 and the report was published in September 2021. It found that most primary care staff viewed A&G as a ‘good concept’, but that it also represents a ‘significant time and resource’ challenge to primary care.
In the survey, carried out between 31 March and 30 April 2021:
- 87% of the 390 respondents said A&G was in place in their area before the pandemic
- 80% said A&G is provided in their area via e-RS
- 74% reported they use A&G more now than before the pandemic
- 71% reported using A&G ‘at least weekly’ over the past year
- 94% said for the services they use most frequently, the process of requesting A&G and receiving an answer was ‘good’ or ‘very good’
- 34% rated the interoperability of the A&G system with the patient’s primary care record as ‘poor’ or ‘very poor’
Respondents also identified the following barriers to the use of A&G:
- Variable or slow response times
- Availability of A&G services
- ‘Clunky’ systems and processes
- Time and workload pressures
- Poor quality of responses
In east London, an audit has been undertaken to assess the impact of A&G services on practices. It claims each episode takes 13 minutes ‘on average’ – seven minutes of GP time and five of staff admin time. Tower Hamlets LMC has asked for GPs to be recompensed £12.50 per episode as part of the Barts trial.
LMC chair Dr Jackie Applebee tells Pulse those figures ‘were as good as we could get, but actually I think they are probably a woeful underestimate’.
She says the audit was a snapshot of two weeks, but the effect on GP workload would be in the longer term. ‘What that audit didn’t do is take into account that we are still holding the care, so patients will keep coming back to us.’ She adds: ‘Expecting us to take all that on when at the moment we can barely do the day job is ludicrous. It’s just completely mad.’
The LMC England conference agenda at the end of last month featured motions calling on the GPC to ensure GPs ‘cannot be mandated’ to use A&G by providers or commissioners, and that GPs ‘retain their ability to refer when appropriate’ without being forced to use A&G pathways.
Watford GP Dr Simon Hodes says when used well, A&G can be ‘an excellent service’ for GPs, but adds: ‘If this is imposed [for all referrals] it will by definition create more work for already overstretched GPs and delays for patients.’
Nottingham GP Dr Irfan Malik agrees A&G is a ‘good system’. But he says the introduction of targets could see more referrals being ‘blocked’ and stepped down to A&G: ‘We’re already seeing that in some specialties in Nottingham where we have referred, presumably for a face-to-face appointment, but what they’ve given in reply is an advice letter.’
Success in terms of cutting referrals can depend on which specialties are involved. For example, in 2019, a teledermatology test scheme in Stockport was proclaimed a success after 99% of queries had responses on the same day, and only 18% of 68 A&G requests over a four-month period resulted in a referral. More recently, Bedfordshire, Luton and Milton Keynes ICS reported that this summer, 70% of dermatology cases where A&G was sought were managed in primary care.
Tower Hamlets GP Dr Selvaseelan Selvarajah says A&G can work well for ‘medical specialties’ such as dermatology, rheumatology and gastroenterology, ‘but not so well for a surgical specialty because you pretty much know the diagnosis and want the surgeon to do something about it’.
‘I’ve seen it not work well for some surgical specialties like urology, and I’ve seen it not work well where GPs ask for a referral, and it has come back as advice… we have to say, no we want you to see the patient. That’s where it can delay things.’
If A&G is to become more common, IT factors will also have to be addressed. The NECS research found most A&G is provided via the electronic referral service (e-RS), but a ‘wide range of platforms’ is being used alongside or instead of this.
Resourcing primary care
Professor Sir Sam Everington, a GP and chair of Tower Hamlets CCG, is more upbeat about the scheme, saying it has the potential to reduce GP stress and see workload properly resourced.
Resourcing primary care is ‘the critical part’ of this and Dr Everington says the CCG is ‘close to coming up with a plan’ foreast London. He highlights other elements needed for a wider rollout of A&G, including standard referral forms and adequate access to diagnostics for GPs.
Without such support, and removal of associated targets, advice and guidance could be just another way to dump work on GPs. And GPs might have a few choice words of advice if that were to happen.
The history of A&G
GPs used telephone advice lines or email to source advice from hospital specialists.
Formal A&G services first established in England in response to the King’s Fund report Referral Management – Lessons for success.
Choose and book system was redesigned and the NHS electronic referral service, or e-RS, was introduced with an advice and guidance feature, allowing GPs to request advice from consultants before or instead of making a referral.
NHS England commissioning guidance set an expectation that A&G be available across services that cover ‘35% or more of the provider referral base’, be consultant-led, and that 80% of all responses to A&G requests be given within two working days.
NHS Long Term Plan pledged a ‘fundamental’ redesign of outpatient services, with the aim of cutting face-to-face outpatient attendance by a third over five years.
• April and July 2020
NHS England letters mentioned A&G as a way of helping to reduce Covid infection risk by avoiding hospital appointments.
• September 2020
NHS England published a series of short guides on A&G, stating that it was essential during the pandemic and changes to A&G delivery could be implemented ‘to maximise opportunity in the management of patients outside secondary care’.
• May 2021
NHS England announced a £160m initiative to tackle waiting lists and ‘develop a blueprint for elective recovery’, which includes ‘greater access to specialist advice for GPs’.
• October 2021
NHS England announced a target for GPs of ‘a minimum of 12 advice and guidance requests to be delivered per 100 outpatient first attendances’ by March 2022.