NHS England backtracks on target for one in four GP referrals to be diverted via A&G

NHS England has written to GPs to deny that there is a national target for referrals being sent back to general practice, and said that requests for referral or specialist advice must now receive a response ‘from a named consultant’.

In a letter to GPs, national primary care director Dr Amanda Doyle said that there is ‘no national target’ for specialists, trusts or general practice to divert ‘a fixed proportion of referrals away from hospital care’.

It comes after pressure from the BMA’s GP committee, which is threatening collective action unless the Government ‘pauses’ its plans around mandated A&G, and it is also currently seeking legal advice on the new requirement, amid fears it removes GPs’ right to refer.

Dr Doyle said that ‘there have been concerns’ about ‘terminology’ used in the neighbourhood health framework, which said that the Government was aiming for 25% of GP referrals to be ‘diverted’ back to GPs via amendments to A&G by 2027 for 10 ‘high volume specialties’.

However, Dr Doyle insisted that the figure quoted is ‘an estimate’ of the potential proportion of patients, who could be ‘appropriately assessed and supported’ by a specialist consultant ‘without a hospital outpatient appointment’, and not the proportion of referrals to be sent back to general practice.

Dr Doyle said: ‘I know there have been concerns about the terminology used in the recently published neighbourhood health framework, in particular that SPoA can contribute to a diversion rate of at least 25%. 

‘But is important to be clear that there is no national target for specialists, trusts or general practice to divert a fixed proportion of referrals away from hospital care.

‘The objective is simply to identify the most appropriate next step for each patient, based on specialist assessment and triage at speciality or sub-specialty level.

‘The figure quoted relates to an estimate of the potential proportion of patients, including those who are the subject of an A&G enquiry, who could be appropriately assessed and supported by a specialist consultant without a hospital outpatient appointment. It is not the proportion of referrals to be sent back to general practice.

‘Where there is clear clinical evidence, the intention is to avoid adding patients to outpatient waiting lists when they can receive timely diagnosis, advice or management in a more appropriate setting.’ 

She also said that it was ‘important to emphasise’ that the clinical threshold for a referral ‘remains unchanged’.

She added: ‘A GPs clinical decision to refer remains unchanged. Where specialist advice is provided but the GP remains concerned that referral is clinically appropriate, there should be a clear route for referral, supported by additional clinical context from the GP where needed, to ensure the most appropriate pathway for the patient is agreed.’

She also said that requests for referral or specialist advice will receive a response ‘from a named consultant’ – following concern raised in Parliament last week that non-doctors could refuse GP referrals.

Dr Doyle also said that where specialist assessment identifies the need for diagnostic tests as part of the specialist pathway, those tests should be organised by secondary care, with results reviewed and acted on by the trust.

She said: ‘These tests should not be returned to general practice to arrange. General practice should continue to arrange diagnostic tests that are routinely undertaken as part of assessment or prior to referral.

‘Where a patient is awaiting tests or treatment in secondary care, as is the case currently, GP teams should continue to escalate concerns to secondary care where clinically indicated.’

GPC chair Dr Katie Bramall said that while the letter was welcome, it does not mean that collective action is off the table.

Dr Bramall said: ‘The letter from NHS England outlines a modified approach to advice and guidance that both reflects and assures the primary concerns of the GP profession.

‘We recognise that our outstanding ask around unlimited and unsafe patient demand remains.

‘GPC England will review all positions, and should those mitigations not be sufficiently met by 30 April, we reserve the right to escalate to collective action beyond this date.’

RCGP president Professor Victoria Tzortziou Brown said: ‘We are pleased that NHS England has listened to the concerns of GPs – raised by the College and others – and has clarified that they will not introduce a target of 25% of referrals to be diverted from hospital care or rejected through advice and guidance, and crucially, that each referral will be reviewed by a specialist consultant. 

‘Doing so would have undermined clinical decision-making and risked increasing workload in general practice at a time when GPs and our teams are already working under significant pressures, as well as creating barriers to appropriate and timely patient care. 

‘As these plans are taken forward, it will be crucial to ensure timely specialist responses, genuinely integrated systems, and the continued protection of patient choice and clinical autonomy.’

This week the GPC advised GPs to demand GMC numbers of secondary care doctors taking responsibility for GP referrals being inadequately turned into A&G.

Last week the primary care minister refused to confirm whether only consultants will be able to divert GP referrals to A&G under this year’s changes to the GP contract.