This site is intended for health professionals only

NHS England ‘working on major expansion of A&G’ prior to GP referral

NHS England ‘working on major expansion of A&G’ prior to GP referral

NHS England is working on a new strategy aimed at further increasing the use of ‘advice and guidance’ (A&G) before GP referrals are accepted.

GPs may be asked to significantly reduce the number of direct referrals they make to hospitals as part of the strategy due by December, the trade magazine HSJ was first to report.

NHS England is working with the Royal College of Physicians (RCP) and other clinical leaders on developing the new strategy for reducing unnecessary outpatient appointments.

Clinical leaders emphasised, however, that direct referrals from GPs must still continue when they are assessed to be clinically appropriate.

NHS England has held four stakeholder events where primary care has been represented. A wide range of ideas have been discussed including the impact on both primary and secondary care.

No decisions have been made on what will be included in the strategy but any decisions about the future of outpatients are expected to take account of the pressure throughout the NHS, Pulse understands.

The A&G pathway involves GPs managing patients whilst accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.

A&G has been used since 2015, however NHS England formalised the pathway in 2021 when it introduced a target stipulating that GPs use it for 12 out of 100 outpatient attendances.

In January 2022, as part of plans to tackle the elective backlog, NHS England increased this target to 16 specialist advice requests, including via A&G, per 100 outpatient first attendances

However, in November, a National Audit Office report showed that GPs were already managing 22 patients out of every 100 they referred via A&G from April to June 2022

RCP outpatients lead Dr Theresa Barnes, who is part of the group working with NHSE, told HSJ there should be a ‘push’ to use A&G ‘in preference to direct referrals’, and also suggested that patients should be able to see, and potentially contribute to, conversations between their GP and specialist clinicians.

Dr Barnes said: ‘I think there should be a push to use advice and guidance in preference to direct referrals, so we can maximise that pre-referral interaction and deliver as much care as close to patients’ homes as they can get it and without the delay of potentially waiting for a secondary care appointment.’

Changes as part of this strategy would require a new commissioning mechanism to ensure clinician time is protected and funded in order to carry out this work, according to RCP clinical vice president Dr John Dean.

He told HSJ that the ‘current mechanisms, e-referral system and advice and guidance, are not fully commissioned at present’ and do not support A&G to be ‘the dominant method of interaction’.

‘[A&G] has to be jointly commissioned between primary, secondary care professionals and patients. Because it’s not just [secondary care professionals] whose time isn’t being properly protected its primary care, too,’ Dr Dean added.

He also told HSJ that the review will include looking at expanding instances where patients can self-refer for investigation of symptoms via ‘one-stop-shops’.

Dr Dean also told Pulse that the RCP is ‘working closely’ with NHSE on the outpatient strategy and that it has been ‘a collective programme with primary, secondary and community care’.

He said: ‘Any recommendations once fully developed and consulted on will need to address any impact on all sectors to improve care for patients. Fundamentally we are all agreed we need a more integrated approach.’

According to data from NHSE’s specialist advice activity dashboard, there were around 200,000 pre-referral ‘specialist advice requests’ in July 2023, and of the 150,000 that were ‘received and responded to’ by a hospital specialist, 70,000 did not ultimately result in a referral.

Professor Sir Sam Everington, a GP in Bromley by Bow, told Pulse the ‘advice/referral’ scheme in his local area ‘works incredibly well’ and ‘takes a lot of pressure off GPs’.

‘You have to remember that because of this waiting list, the consequence of the 7.7 million now on the waiting list, is that we’re managing, we’re holding these patients in primary care. At least a quarter of our workload is managing patients on the waiting list, who are sitting on the waiting list and getting more ill.’

Professor Everington said he recently attended a meeting with the NHSE chair to make the case of advice and guidance pathways.

‘My view is that the GPs will get far more support if every referral is sent to a specialist team and then the specialist team triage and make a decision about what is the most effective way of managing the problem that the GP is giving them.’

‘The secret to this is to ensure that the GPs are supported and resourced to make this happen. That’s what we’ve done in Tower Hamlets – that’s not being done elsewhere.’

NHS England provided background information but declined to make a statement.



Please note, only GPs are permitted to add comments to articles

Michael Mullineux 20 September, 2023 11:26 am

So patients can refer themselves directly but GPs will need to use A&G which is currently unfunded?
NHSE and RCGP as incoherent and keen to dump additional worload on GP as usual for the sake of the mythical ‘integrated approach’

Nick Mann 20 September, 2023 11:42 am

“…of the 150,000 that were ‘received and responded to’ by a hospital specialist, 70,000 did not ultimately result in a referral.”
“Ultimately” or immediately?
And what of the other 50,000?

A&G is ok in its place. Our entire Practice spent hours every single month auditing referrals to reduce inappropriate referrals. There were very very few and most of them were dependent on the gp’s level of experience.

Complaining about NHS inefficiency and wasteful use of resources, whilst in the same breath recommending expansion of patient self-referral at will is just stupid.

Reminder: gatekeeping by GPs is highly efficient and cost-effective for both NHS and patients. We used to have regular meetings and communication with hospital consultants/registrars to improve specificity and work-up of patients pre-referral. No time or capacity for this now.

I can feel a headache coming on…I think I need to see a neurologist.

Michael Crow 20 September, 2023 11:48 am

Thank goodness I have just retired. My experience of A&G was that it never altered my decision to refer. It did however take a lot more of my time and when I became a locum in the latter part of my career made things very difficult as I was not always there to speak to the consultant. This does not appear to be considering the extra time required by GPs and therefore potential further reduction of capacity of GPs. Why is the GP on the panel not representing the issues for GPs?

Simon Gilbert 20 September, 2023 11:53 am

The obvious work around here is to massively increase minor advice and guidance referrals in order to ensure one’s % conversion rate is low enough that you can actually get a patient seen when you don’t know what is wrong with them, are not aware of your unknown unknowns and have, in your trained professional opinion, reached the point where a specialist is justified.

Not on your Nelly 20 September, 2023 11:54 am

Does Dr. Barnes do Any clinical work. It doesn’t seem like it from her comments. If GPs lose the ability to refer, they have lost a significant part of their job and patient safety is at risk.

Simon Gilbert 20 September, 2023 11:54 am

See how a communist system perpetually works to turn away all customers.

In another world providers would shout from the roof tops to both GPs and patients as to how great they were, how short their wait time is and how their good looking, well trained specialists can’t wait for the referrals to roll in!

Rogue 1 20 September, 2023 11:59 am

Same here, going through the referrals the other year it never changed the decision to refer.
Is only created a whole load of work for the GP to do, then review the patient, before referral
So it just used to use up more appointments and created more unfunded work! (because when the hospital does the tests they get paid for them!?)

David Church 20 September, 2023 12:05 pm

This is nothing to do with a ‘communist system’ – communist system would allow referrals, whislt the current capitalist system is trying to block NHS referrals so that patients are forced into the corrupt, greedy, self-advertising, exploitative capitalist private healthcare system.
Let us not misunderstand this.
Isn’t it funny how in the old days GPs would know their local consultants, and could seek advice personally by contacting the consultant of choice direct or through the secretary; but modern systems prevent, almost completely, this direct contact with a local specialist who knows the GP’s level of experience and confidence, the local service area, local population, and local hospital facilities. Instead, we get phone access to a DISTANT consultant, who may be a superspecialist (though we often don;t want an ideal response), and does not know our local hospitals, facilities, distances, or consultant specialisms, or who is available at the local hospitals for an urgent face-to-face if one is needed. No, definitely not making it local, making it distant and impersonal instead.

Andrew Schapira 20 September, 2023 12:11 pm

I have referred many patients through advice and guidance there is an assumption that we always get a response which is not true and it is difficult to keep track of referrals therefore on balance may not be safe with the present IT

Steven Berg 20 September, 2023 12:29 pm

I agree with Andrew Schapira, and also with Michael Crow – being a locum the lack of continuity of care does not make A&G an effective nor a safe way of patient management, after all, we are generally referring for a reasonable reason and A&G merely adds a layer of administration and delay for the referrer (if we EVER get an answer) and a can be a potent cause of stress for the patient who really doesn’t know what to expect, especially when their GP admits to needing some help with their problem – GMC tells us to be open and honest (and more recently, kind) at all times.

Centreground Centreground 20 September, 2023 12:44 pm

At least now we are being warned NHS England is working on another project so at the very least we all can prepare for the next potential impending NHS catastrophe cooked up by this dubious group.

SUBHASH BHATT 20 September, 2023 1:01 pm

Looks like dangerous triage by consultants. I spoke to one consultant who says if gp want us to see patients we will take no risk saying “no”. . .

David jenkins 20 September, 2023 1:43 pm

explain to the patient that you have referred them, and give them a copy of the letter.

if – like me – you are a locum, and you are not there regularly, you need to make sure they do not fall through the net.

explain you have to do it this way round, and explain that if they – the patient – rings the hospital, they are more likely to be listened to than we are.

don’t forget to put on the referral letter that you have given the patient a copy – just in case it gets “lost” or misfiled somewhere along the line. and ALWAYS keep a copy of the referral letter.

i know this is all extra work, but remember the two words that force you to work like this………………..


David OHagan 20 September, 2023 1:56 pm

I’m sorry Sam are you sure you are still seeing patients?

Your Rheumatolgist chum seems to want to see more ‘fibro’ and ‘i’m sure it’s gout’

Better working together is important, but this is not the way.
(note NHSE seems to be paying RCP to ‘come up with’ / ‘front’ this latest nonsense idea; RCGP response not mentioned above)

Cameron Wilson 20 September, 2023 2:11 pm

And then A+G will be outsourced to some faceless outfit at the End of the World!
NHSE are playing a different game to us, all about bailing out Politicians, certainly not about quality!
Definitely not about taking pressure off Primary Care, different story for Secondary Care tho!!

Some Bloke 20 September, 2023 4:49 pm

We should take collective action. All refuse to participate in this Mickey mouse medicine.
The idiots have given us the focus and means of strike action that doesn’t affect patients care or finance of the practice

neo 99 20 September, 2023 5:22 pm

The primary role of general Practice at inception has been one of a gatekeeper. The systems set up in general practice such as seeing undifferentiated illnesses across multiple disciplines at large volumes within short time frames were for this role. Over years, this continues but we now have the additional role of being in essence general physicians diagnosing and treating patients outside our level of competence within a less than 10 minute time frame with no new training or time or funding. A and G adds to this burden needing multiple appointments to address issues we would have previously referered appropriately and takes time away from the gatekeeping role. The work up requested by secondary care prior to accepting a referral has become ludicrous with hoop after hoop. This is risky work and really not efficient. Not really what I signed up for as a GP and not what patients want either. I don’t don’t want to be a house officer all over again. The waiting list is a political choice not one of my making and not really my problem.

Michael Green 20 September, 2023 6:51 pm

Hands up who has ever had a useful response from A&G?

Ravi Sastry 21 September, 2023 1:34 am

There is no gp input onto a stream of work which mainly tells GPs how to work !
Why is it right we hold all the risk and get blamed for delayed investigations & treatment?
It’s cheaper to see gp so get them to work up all patients and carry all the risk. So patients with non specific presentations and rare conditions get substandard care and access to specialist.
We are not their clerking house officers ffs.

A Non 21 September, 2023 8:14 am

Perhaps a statement of the bleeding obvious but the NHS is going down. Having found temporary refuge in a non clinical role about a year ago, observing from my hastily constructed dug out on the beach through hazy binoculars provided by Pulse, I feel bizarrely like Harry Styles in the film Dunkirk, desperately trying to escape the beach.. more and more convinced as every moment passes I can never go back. Almost inevitably soon to become an anonymous negative digit in a Pulse article on the performs list. Lost in action. Exhausted, desperate, defeated, now feeling like a beaten coward, as others still fight. Had enough.

David Banner 21 September, 2023 9:00 am

Everyone knows A&G is a cynical method of reducing OPD waiting lists by dumping the work and medicolegal responsibility back on to the GP.

I would suggest that every rejected referral receives a counterblast standard letter stating that you the GP remain of the professional opinion that the patient requires Secondary Care input, and that medicolegal responsibility remains with them, not with you.

Then inform the patient that your reasonable referral has been rejected and to send any complaints directly to the relevant Secondary Care secretary or the hospital’s Clinical Director.

If we all do this, A&G will collapse, especially as the Public wake up to the fact they are being hoodwinked by a slippery Secondary Care rather than failed by a bungling incompetent GP

Dunit GotheTshirt 21 September, 2023 9:52 am

Yet another nail in the coffin of General Practice.

Rogue 1 21 September, 2023 10:30 am

Not a bad idea David B. Do you think the BMA could come with a suitable letter to bounce these back to secondary care?

Centreground Centreground 21 September, 2023 10:34 am

An unfit for purpose NHS England combined with incompetent NHS managers pushing these agendas such as A & G who historically rise to positions of power with no accountability or qualifications to back up these positions. Even within Primary Care -Practice Managers with no qualifications having just drifted into assistant practice manager positions and then practice manager roles simply due to lack of appropriately educated and trained managers and then to the ICB or even the mysterious NHS England roles have no real understanding of medicine or the risks taken by clinical professionals . They simply regurgitate information from the countless paid meetings they attend without ever doing any personal study yet direct highly qualified professionals in their specialised roles- this is no longer acceptable. Some smaller numbers of course are worth their money but the majority are not and are there by default. This whole NHS management system needs tearing down and rebuilding to restore at least the possibility of hope.

David Mummery 21 September, 2023 4:45 pm

Under patient choice legislation patients have a legal right to see a specialist if that is their wish

Andrew Schapira 21 September, 2023 6:08 pm

Some thoughts
Sounds as though it is a political move to massage waiting list figures ( the next election is coming)
Not sure I have seen evidence of benefit or safety from pilot studies
What is the cost ( extra man hours etc )to primary care because I’m not convinced that this is cost free to primary care
But in certain circumstances when I have used it it has been valuable

Imogen Bloor 21 September, 2023 8:59 pm

Well said David Church, I agree wholeheartedly..
the concept of Advice and Guidance is useful, and was always available, albeit informally .
The change to A&G ( or variations such as Consultant Connect’ ) has monetised the process, with the cost of jeopardising collaborative relationships with local secondary care colleagues. Ironic in an era which promotes integrated care, around the concept of ‘place based ‘ care.

Dave Haddock 24 September, 2023 12:06 pm

Please could we replace the NHS with something that works?
Perhaps look abroad and see how other countries manage healthcare?

Truth Finder 26 September, 2023 5:18 pm

The big picture is too many chiefs and not enough Indians. More chiefs=more useless bureaucracy to slow the workers down causing system collapse.