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Major hospital trust could make ‘advice and guidance’ mandatory following trial


elective care


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.’

It comes as NHS England has set an A&G target across the country in a bid to curb GP referrals to hospitals.

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.

READERS' COMMENTS [26]

Bonglim Bong 25 October, 2021 5:55 pm

I assume Barts NHS Trust will be commissioning and paying for the enhanced service to cover all the extra workload? And of course making it optional.

In the week when the BMA has suggested practices bounce back all uncommissioned work or indeed all work that is not part of the core GMS agreement – this comes across as a bit tone deaf. I’m sorry that hospital trusts are struggling with workload, but dumping that on another creaking part of the health service is not the answer. Perhaps a bit more actual innovation is needed:
what about a team of admin employed by the hospital to organise pre-clinic tests, with the requests signed off by consultants?
what about making sure that every clinician has a named FP10 pad and Med 3?
What about setting up an interface so patients can communicate directly with their clinicians after clinic appointments, so that they do not go back to their GP?

Funnily enough I can’t see Barts spending their own money on those services, so the attempts to pass work on to GPs should also be politely declined.

Nicholas Sharvill 25 October, 2021 6:45 pm

one assumes that the private sector will echo this if it is good clinical practice; one assumes the insurance industry would be keen-not too sure re those paying premiums.!

Reply moderated
James Cuthbertson 25 October, 2021 6:46 pm

….and many thanks for your advice. However if you feel there is any risk whatsoever in you not seeing the patient face to face please feel free to see them in a safe time frame. And of course be aware any tests you want need organising and following up by you. Best wishes some GP…..,

Sam Tapsell 25 October, 2021 6:56 pm

I would value this more if the specialist had access to the GP record.
Recently had advice to try tamsulosin in a man who presented in acute retention who I catheterised and referred. My brief letter mentioned he had been taking it for 2 years…

Patrufini Duffy 25 October, 2021 7:16 pm

That’s a joke. So who’s door is actually closed Sajid, still? GPs over the years save millions of referrals out of their good will malarky, and being the holy generalist. I hope the GMC, Ombudsman, CQC (let’s ofcourse keep this partially safe and effective and responsive ??!!**) and patient are well aware of patient does NOT come first, and the new “you sit quietly in the community and bugger GPs for an effectively free tariff, or go private, until your condition or your ego feels like suing someone” is the plan:

Bart’s private healthcare…
https://bartshealthprivatecare.com/about-us

Anthony Matheson 25 October, 2021 7:34 pm

Cheeky sods. The receiving specialties could do with a bit of guidance and advice whether it’s a very junior doctor or a consultant taking the call:
1) You haven’t seen the patient.
2) The referring GP is a fellow doctor, not some kind of lesser being and has seen the patient. If they feel the patient needs admitted rather than just getting some specialist advice, the patient should be admitted. No argument.
3) Don’t talk down to or be rude to anyone on the phone.
4) Stop protecting your little fortress which leads to GPs being pushed from pillar to post. We are a team after all. It takes long enough to see, assess and sometimes treat a patient before admissions let alone writing the referral letter to whoever has given in and decides to see your patient.

One can only dream. I work in A&E now. Give us a phone and hopefully you’ll get to speak to someone sensible. Once you send your patient in via A&E with your letter addressed to the receiving specialty, I just phone them up and say “your patient is here”. Bingo.

IDGAF . 25 October, 2021 7:44 pm

Anyone here remember being a very junior hospital doctor and calling your registrar for some advice, and, appropriately, the registrar whose understanding exceeded yours would ask for some salient points from the history, examination and the work-up done thus far by you in order to make a valid appraisal of the situation? And if some of these points the registrar wanted information on were not addressed by your evaluation they would suggest getting these elicited/done and then getting back to them unless it was a life-threatening situation. In theory this is a good way to work, learn and develop, but I suspect that many GPs who operate under time constraints and regard themselves as “expert generalists” already will find this mode of working as something which will engender resistance, a feeling of defensiveness as their assumed depth of knowledge will be found to be sub-optimal and necessitate having to see the patient more times than previously when the referral process was less restrained in order to gather the information required by the specialist.

The pandemic has shown the weakness of primary care in terms of understaffing, relentless demand and depth of knowledge required to operate without the safety-net of secondary care being within ready reach. Some of these issues are more readily addressed than others but I hope that all those involved in GP education reflect honestly on what has been exposed in the past 18 months.

Patrufini Duffy 25 October, 2021 8:01 pm

Can you imagine the new MRCGP CSA case: “There’s a demanding 24 year old wanting a gynaecology referral”. What do you do, after your not so nice ICE…well, you decide to block the referral and say you’ll get some advice.
FAIL. Patient unmet needs ei? Take that PUN out of appraisal too.

Bryan Morland 25 October, 2021 8:01 pm

not keen on this idea at all. Say a locum sees 20 patients and sends 5 or 6 A+G. These then bounce back to the regular docs who will need to contact the patient and start all over again. In a system with ever decreasing continuity this could double workload. Nice from secondary care perspective.

Simon Gilbert 25 October, 2021 8:04 pm

We are not funded to do the amount of work expected by commissioners.

David Evans 25 October, 2021 8:29 pm

Interesting idea but who will take the medico-legal responsibility for an adverse event as a result of this triage process ?
Referring GP or Advising Specialist ?

James Cuthbertson 25 October, 2021 8:35 pm

Bryan Morland good point

David Mummery 25 October, 2021 8:38 pm

A&G is a gaslighting con-trick on Primary Care to keep all the clinical risk in GP. We’ve always been able to get ‘advice’ – just pick up a phone and beep someone. We refer when we want and need a specialist opinion and investigation. In terms of liability, the trusts are sharing in very thin ice: medico-legally speaking the only person who can say whether the referral is ‘appropriate’ is the referrer. Also patients actually gave a lot of medico-legal leverage to say that they want to see a specialist. This will end up in the courts…

Slobber Dog 25 October, 2021 8:59 pm

Often wondered whether schemes like ‘clinical thresholds ‘ and referral to ‘triage ‘are designed to make the referral process easier or harder.
Pretty sure it’s the latter.

neo 99 25 October, 2021 8:59 pm

This is a disastrous and unsafe idea and clinical specialism in the UK continues to become a smaller inaccessible cocoon within which consultants operate. General practice has always been a gatekeeper role and the ability for onward referral when you reach the limits of your skills and knowledge base is essential and is a part of the GMS contract . GPs are an eclectic group with core skills but variable speciality interests and skills acquired over years of experience. Hence different thresholds for referrals. This is a high risk strategy and the risk unacceptably stays with the GP for work outside their area of expertise. I am sure the defence unions would have something to say about this. This will also just exacerbate access issues in general Practice as it is not set up for this additional work. The only way it would work is if the specialist took the clinical risk and all responsibility for arranging, reviewing and communicating any investigation or action in a virtual clinic which if you really think about it is really a referral! I am all for upskilling myself but this takes things a bit too far.

David Banner 25 October, 2021 9:04 pm

Re medicolegal responsibility, it’s all well and good to say we referred them to secondary care, then secondary care bounced them back, but once returned to our court with a list of jobs the responsibilities remain with us until we tick the boxes and refer back. Inevitably some punters will be lost in the system, and when they hit the rocks the finger of blame will still point at us. and the extra faff of chasing up patients already frustrated by delay so we can check their vital Vit D levels will be a most unwelcome extra burden.

As Admiral Ackbar famously said, “It’s a trap!!”

ANTHONY Roberts 25 October, 2021 10:26 pm

What will happen if all the GP”s in the area decide to refer to a different trust and the CCG decides to commission it”s hospital services from elsewhere?

Josef Kuriacose 26 October, 2021 6:07 am

Does that old chestnut that a patient can express a desire for a second opinion still exist as a right?

Tim Atkinson 26 October, 2021 5:33 pm

I wonder what Javid thinks of this Trust making it harder for patients to see a consultant f2f?

Jolyon Miles 26 October, 2021 6:24 pm

I would argue that once a referral has been received and processed the responsibility lies with the ‘directing mind’, ie the hospital doctor. I think the case for hospital doctors managing their own results has already been made and that this is a logical extension.
It is very poor management that issues high handed dictats without consideration of the whole system consequences.
My advice #justsayno

James Weems 27 October, 2021 10:38 pm

If implemented needs commissioned risk/gain share of funding back into primart care. End of story.

Keith Greenish 28 October, 2021 8:54 am

Another example of hospital trusts totally ignoring the Standard Hospital Contract and abusing Primary Care in order to make their own lives easier

Richard Greenway 28 October, 2021 12:50 pm

Agree with all of this. Advice and guidance has a place but has to be timely -ideally immediate/ phone based.

There are times when we want to be guided but times when we need to refer because unsure , require a procedure, or an opinion. Most of the rejections we get are procedural (boxes not ticked) which again wastes time and is ultimately not in patient’s interest.

A&G adds another step to every referral which we have to have processes to check, and creates 2consultations for every referral, and we will carry the can of clinical responsibility. If I was in London I’d be sending my patients elsewhere.

Shahid Dadabhoy 28 October, 2021 1:31 pm

IIRC Copperfield predicted this weeks ago?

Angus Ross 29 October, 2021 2:17 pm

I like A+G – It is easy to convert them to formal referrals, urgent if necessary, if in your clinical judgement the advice is inappropriate.
I have some concerns about A+G becoming the default however, although it may work fine.
Like everything else imposed on GPs, the line of least resistance will be found – I have referred a couple of (neurological and deemed not to need an appointment) patients formally to alternative trusts when not happy with the original A+G – the alternative trust was happy to take the referral. One patient turned out to have MND.
The best case scenario would be that :
1) For urgent cases – mandated A+G with a rapid specialist response and open dialogue would lead to patients requiring urgent appointments to be seen quicker. I’d feel more comfortable with this than waiting 4 weeks or more for an ‘urgent’ appointment.
If not then there will be an increase in acute admissions at the trust. Not good for the trust and it would have to re-think.
2) For less urgent cases, appropriate A+G advice regarding further open access investigations, subsequently reviewed by the specialist leading to a more convenient (for the patient) and timely investigation and diagnosis of the problem.
If not, patients will be referred elsewhere – also not good for the trust.
Like most things, it will all be about the execution of the plan.

Angela Parker 1 November, 2021 11:51 am

This could also be replaced those Weekly postgradcentre meetings where GPs and consultants met F2F and discussed stuff – The consultants dining room needs to come back too so internal referrals get triaged by F2F discussion over a proper lunch band everyone respects and learns from each other