GPs have been told they must ask hospital colleagues in advance of referring patients for outpatient appointments, so that these are not referred ‘unnecessarily’.
NHS England set out that by March next year, GPs must use ‘advice and guidance’ for 12 out of 100 outpatient attendances, as it struggles to to reduce the elective care pandemic backlog.
This involves GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.
But GPs have warned that advice and guidance (A&G) is yet another form of ‘workload dumping’ from secondary care and cautioned patient referrals may be declined in error.
New NHS England planning guidance for the second half of 2021/22 said that accelerating the restoration of elective and cancer care while ‘[transforming] the delivery of services’ is one of six key priorities for the period.
The document, published yesterday, said that systems must ‘continue to work collaboratively to optimise referrals and avoid asking patients to attend outpatient services unnecessarily’.
It added: ‘A minimum of 12 advice and guidance requests should be delivered per 100 outpatient first attendances, or equivalent via other triage approaches, by March 2022.’
All systems will have to ‘demonstrate monthly increases in referral optimisation, with assessments to monitor the impact on avoiding referrals and on improving patient experience and outcomes’, it said.
NHS England said this aims to support the delivery of wider targets on reducing waiting times for elective activity and urgent suspected cancer referrals.
Systems have been asked to:
- ‘Eliminate’ waits of more than 104 weeks for elective care by March 2022 ‘except where patients choose to wait longer’ and ‘hold or where possible reduce the number of patients waiting over 52 weeks’
- ‘Stabilise’ elective care waiting lists at ‘around the level seen at the end of September 2021’
- Restore ‘full operation’ of all cancer services, including returning the number of those waiting to be seen following an urgent suspected cancer referral for longer than 62 days to February 2020 levels by March 2022
- Ensure that ‘at least’ 75% of these patients have cancer ‘ruled out or diagnosed within 28 days of referral for diagnostic testing’, with full implementation of FIT tests and colon capsule endoscopy ‘where appropriate’ if the lower GI pathway is a ‘barrier’
Professor Azeem Majeed, professor of primary care at Imperial College London and a GP in Clapham, told Pulse: ‘A&G can work well where it is used appropriately but it can also be a mechanism for pushing work away from outpatient departments into primary care.
‘The policy will need careful evaluation to ensure that patients are not inappropriately declined an outpatient appointment; and that GPs are not left with a long list of tasks – sometimes very complex – to carry out.’
He added that the elective and cancer care targets ‘will be very challenging’ and that that he ‘would be surprised if the NHS met them all’.
A recent BMA GP Committee bulletin said that while A&G can be ‘helpful when clinically appropriate’, the BMA 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 amid reports that one LMC was invited to sign up to a local scheme to use A&G before making referrals.
Meanwhile, the Government’s ‘Build Back Better’ Covid recovery plan – published last month – also suggested that GPs were set to manage more patients with specialist advice from hospital colleagues.
It said: ‘NHS England and Improvement will ensure the system is flexible so that people can access rapid advice when they need it.
‘As well as ensuring that patients with suspected cancer and other urgent conditions come forward to access health services, there will be specialist advice for primary care to enable a patient’s care to be managed in the most appropriate setting.’
The Department of Health and Social Care (DHSC) did not respond to Pulse questioning on whether this referred to A&G schemes and whether there were any plans for all non-cancer referrals to go through A&G first.
The new NHS England document added that systems must ‘engage fully in the national clinical validation and prioritisation programme to ensure continued improvement in waiting list data quality with a regular cycle of clinical validation and prioritisation’.
It previously suggested that GPs could be asked to review hospital waiting lists for elective care to help prioritise and manage patients – saying they must ‘jointly manage’ patients stuck in the pandemic backlog with hospitals.
Meanwhile, the document also said that data on waiting times for long Covid clinics would be published ‘from this autumn’ and that systems must ‘address variation in referrals against expected need and take action to minimise long waits for assessment’.
It comes as another NHS England planning document, also published yesterday, revealed that GPs are to receive funding to support them to deliver pre-pandemic levels of appointments, including face-to-face-care.