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NHSE sets ‘advice and guidance’ target in bid to curb GP referrals to hospital


elective A&G


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’.

Last month, the Government said that artificial intelligence (AI) in GP practices will help manage patients in the elective care backlog.

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.

READERS' COMMENTS [18]

Chris GP 1 October, 2021 11:08 am

Easy – I will just write a frivolous letter once a week to ask, for example, if it is ok to put this diabetic patient on a statin for their cholesterol of 7.0. The advice will come back as “yes”. Job done , target met.
If anyone would like to offer any more reasons to make this job crappier than it already is please do bring them forward – I am actively looking for the straw to break my back so I can do something more rewarding with what remains of my life.

Reply moderated
Dylan Summers 1 October, 2021 12:35 pm

I understand that my CCg is looking to integrate the streams such that hospital can respond to referral with advice and can respond to a&g letter with appointment if they wish.

This seems pretty sensible to me.

Sam Tapsell 1 October, 2021 2:52 pm

2w ago I saw a man in urinary retention, already taking tamsulosin. I inserted a catheter and referred to urology, checking renal bloods and PSA with above all in a brief letter.
I was advised to start tamsulosin, check PSA and renal bloods and remove catheter after 2 weeks.
This is a bit like “half of people dont need to be in A&E”, but you dont know which half until assessed by a skilled clinician…

Patrufini Duffy 1 October, 2021 5:15 pm

You are Consultants in Triage and Referral. Told not to refer and short-change people against your hallowed “gut feeling”. It’s not a gate anymore, feels like a door or rabbit hole – which circles back onto your desk.

Richard Singleton 1 October, 2021 6:54 pm

Is this the same NHSE that recently said we are not doing enough 2ww cancer referrals?

Sam Macphie 1 October, 2021 7:16 pm

Truly, more real hospital beds, wards, A & E departments, cancer clinics, (not just done by locum consultants on a weekend to supposedly help to reduce backlogs, when in fact every piece of work has to be redone by the regular Monday to Friday consultants and input on their computers), and MH access everywhere are needed, otherwise the same old backpressures on GPs will continue, with these senseless policies to underload secondary care.
It seems consultants and NHS expect GPs to do their jobs for them with little left for them to do. And how much is this costing the UK, to get it all wrong? financially and otherwise, (with GPs overloaded and unhappy patients on neverending lists).
Backpressures (and GPs duplicating and re-duplicating their hard work) will get worse and more anger from patients. Army field tents outside A & Es and frustrated paramedics in backing up ambulances outside A & Es , with declining fulltime GPs, will not be a sustainable solution.
Great comments from wise and concerned GPs.

Simon Gilbert 1 October, 2021 9:21 pm

Apparently ‘doing’ is out of fashion for everyone except GPs. Even the specialist nurses and mental health social workers drafted to help the consultants prefer to advise GP to do x,y and z.
We need people to ‘do’ not order us about.

Deborah White 1 October, 2021 10:08 pm

Of course, this is largely a deckchairs and Titanic sort of situation, and we can all see the issues with this from the GP-side, but I would be interested to hear how A&G is integrated into consultant job plans, or are they expected to squeeze it into “magic time”, as with many things asked of GPs?

Twenty 1 October, 2021 10:48 pm

@chris GP,, that’s only another stick to beat u with, “8% of GP referrals inappropriate”, your referral needs to read “ does this patient with an abdominal mass need to be seen? Please convert to an appointment if approprriate “

David Mummery 1 October, 2021 11:06 pm

A&G is gaslighting and a total con-trick on General Practice

Alfred Brown 2 October, 2021 3:40 am

Can we insist they inform us before they discharge (dump) patients?
Let’s make sure we document the refusing clinicians name ready to hand them over to the coroner, GMC etc

nasir hannan 2 October, 2021 7:55 am

So a piece of work was done on this by a practice in Hastings and was really effective. They referred evey referral they made to advice and guidance. I think that they still did urgent and 2ww as normal. There was a reduction in referral and actually the patient got a plan. It was actually win win. As long as gp’s are funded for the extra work, the hospital consultants have this appropriately put into their job plan, it could be really good. It will require joint working with NHS E, gpc and the BMA consultant body.
The long wait times are not benefitting anyone.

Andrew Jackson 2 October, 2021 2:26 pm

we have had AandG in our area for a while.
It really only works for problems where the decisions are made on specialties that look at blood indices eg haematology renal and some liver gastro
It fails when the referrral includes a need to examine to plan surgery or when there are subjective symptoms eg pain
education of the consultants is really important on how to reply as they need to provide a stepped mx plan rather than just a single action that usually leads to a further A&G after this
an expansion would have to be resourced on BOTH sides

Andrew Jackson 2 October, 2021 2:27 pm

also ECG interpretation

Iona Collins 3 October, 2021 8:22 pm

An outpatient referral from primary care to secondary care is mainly in the form of a letter, which is requesting an opinion. The letter is not requesting a hospital review. The outcome of the letter may be a hospital review, or feedback following MDT discussion, or an opinion by return of letter.
An on call referral from primary care to secondary care is mainly in the form of a phonemail, which is requesting an unscheduled/more immediate opinion. The phone call is not requesting a hospital review. The outcome of the phone call may be a hospital review, or feedback following consultant discussion, or an opinion following on call hospital patient review.
The only referrals without initial communication are direct patient-instigated self-referrals to A+E.
So- what is the point of this new target, or am I missing something here?

Nicholas Marotta 4 October, 2021 2:02 pm

all referrals are A+G in Gosport and it works well as you get an answer in a few days eg opinion on a rash or what do I do next and generally the ones you think need referring they just convert to referral or occasionally they tell you do do something pretty simple which avoids the referral. I like knowing what they think in a short period and it means some people get consultant opinion in few days rather than weeks or months

Patrufini Duffy 4 October, 2021 3:26 pm

You save the money. And see none of it in return.

Nicola Williams 6 October, 2021 7:49 pm

If the faceless NHS England bods wish to sit in my surgery and take responsibility for any harm that comes to patients as a result of further delaying a referral , I will happily let them. If I am taking responsibility for the outcome I will refer what I feel needs referring . Referral is generally a last option anyway as it involves so much work- C+B paperwork, writing a letter then trying to remember which departments accepts letters in which form / have I used the latest updated version of the same etc etc .
The waiting lists are not GPs fault . There has been a pandemic I believe that seemed to have caused a lot of work for everyone in the NHS .