A major London hospital trust has launched a trial requiring GPs to use advice and guidance (A&G) services before referring patients.
The trial currently spans 13 specialities but if successful, the measure ‘could become the default’ for all services across the trust.
Barts Health NHS Trust announced last week that ‘from this month, GPs wishing to refer a patient into some Barts Health services will first need to consult with hospital specialists’ via A&G.
It said: ‘The change is being trialled across 13 specialities and could become the default for all of our services.’
The specialities covered by the trial are cardiology, dermatology, diabetes, endocrine, gastroenterology, general paediatrics, gynaecology, haematology, hepatology, neurology, respiratory, rheumatology and urology.
A Barts spokesperson told Pulse that GPs will no longer be able to make ‘direct referrals’ to these specialities and that A&G will become the ‘single point of access’ to the service.
GPs will have to request the A&G function on the e-referral service (eRS) used by the trust and the request will be converted into a referral ‘where appropriate’, they added.
They will receive a reply from the hospital specialist ‘within five days’, either with advice on how to manage the patient themselves or informing them that the hospital will organise an appointment, the trust said.
GPs use A&G to get advice from hospital colleagues on ‘the appropriateness of referrals’ as well as on treatment plans and test results, it added.
It said: ‘The interaction can help primary care clinicians to continue to care for a patient away from hospital (in the community), or it can be converted into a referral and an outpatient appointment is organised at the hospital.’
Barts is ‘working closely with patients and primary care partners to evaluate the effectiveness of this approach as it’s rolled out’, the spokesperson said.
The hospital trust said that the number of A&G requests it receives increased ‘significantly’ during the pandemic, rising to around 2,500 A&G requests per month currently.
These help GPs ‘manage patients in the community’ and reduce ‘unnecessary hospital appointments’, it added.
Dr Neil Ashman, Barts Health director for clinical transformation, said: ‘Whilst this may seem like a small change to how we run our services, A&G has a big role to play in ensuring we provide the best care first time for patients in the most appropriate setting.’
A spokesperson added: ‘North east London clinicians have led the way in adopting A&G during the pandemic with the greatest number of requests of any London region. This approach, which has been adopted by other trusts across the country, is crucial to getting patients access to the information and support they need, in the most appropriate setting, as quickly as possible.’
Hackney and City LMC chair Dr Vinay Patel told Pulse the measure is unacceptable if it leads to GPs facing rejected referrals.
He said: ‘If it’s going to be a way for them to triage and bounce back referrals or give GPs – you know, do x, y and z investigation and then get back to me – then I don’t think that’s acceptable.
‘Is this going to lead to more referrals getting rejected and further work our end?’
Dr Patel, who is also Springfield Park PCN clinical director in Clapton, added: ‘While completing appreciating the pressures on outpatients, I don’t know if blanket everything goes to A&G first is correct.
‘If we want advice, we’ll use our A&G for the advice. If we want them to be referred, we’ll refer them, so that’s more than slightly unpalatable.’
The BMA previously said that while A&G can be ‘helpful when clinically appropriate’, it is ‘concerned about any scheme that compels its use before referral for further specialist assessment’.
It added: ‘This could result in unnecessary and avoidable delays to care and additional unresourced transferred workload in primary care, thereby impacting the care of others. It could also result in greater medico-legal risk if GPs became responsible for patients and treatments they did not have the competence to deal with appropriately.’
A&G must be ‘adequately resourced and appropriately commissioned with the wider implications for general practice assessed’ if it is used as part of referral or waiting list management, it added.
It said: ‘Unfunded transfer of workload into general practice is unacceptable as this not only adds further burden to an already overstretched service but also has the potential to worsen access to general practice services for all patients.’
By March next year, GPs must use A&G for 12 out of 100 outpatient attendances, as part of measures to reduce the elective care pandemic backlog.
But GPs have warned that A&G is yet another form of ‘workload dumping’ from secondary care and cautioned patient referrals may be declined in error.
A&G involves GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.