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.
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.