London trusts halt A&G ‘single point of access’ after GP concerns it would block referrals

Exclusive A group of hospital trusts in North West London have decided to pause plans for a ‘single point of access’ for referrals, following concerns that this would prevent GPs from sending referrals without seeking advice first.

Londonwide and Surrey and Sussex LMCs raised concerns after the trusts notified GPs that they would switch off the direct referral function within electronic referral systems for five specialties, meaning GPs would only be able to seek advice first, as part of its rollout of single point of access.  

The LMCs pointed to NHS England guidance stating that that advice and guidance (A&G) and single point of access pathways should be co-designed with local GP leadership, and said that this ‘has not been the case’ in North West London, in a letter to the North West London Acute Provider Group, which includes Chelsea and Westminster, Hillingdon Hospitals, Imperial College and London North West University Healthcare.

GP practices in England are required under this year’s contract to use A&G across specialities ‘prior to or in place of a planned care referral where clinically appropriate’, with single point of access routes to be finalised locally by 1 October.

The LMCs said that the pathways ‘were not discussed in advance’ and that they were first made aware from communications sent out to all GPs in early April regarding ‘switching off the direct referral function’ within e-RS for five target specialities, ‘with only the ability to seek advice first’.  

Pulse understands that the five specialities were:

• Cardiology – heart failure 
• Gastroenterology
• Nephrology 
• Neurology 
• Rheumatology

The letter said: ‘While we are aware of national timelines regarding the rollout of this process, the guidance is clear that these pathways should be co-designed and agreed with local GP leadership.

‘Despite significant efforts and progress in establishing and supporting interface groups across NWL the SPoA pathways were not discussed in advance with their members, nor with Local Medical Committee representatives.’

NHS England previously said that ‘there will be nothing that removes the right of GPs to refer’, but that when single points of access will be rolled out, GP practices will be asked to send referrals without specifying whether they are for an appointment or A&G, and trusts will ‘sift them at their end’. However, these pathways need to be agreed with local GP practices first.

The LMCs referred to NHS England’s guidance which ‘makes clear that the clinical threshold for a referral remains unchanged’ and ‘reiterates the importance of involving local GPs in the design and refinement of pathways’.

The letter added: ‘It is important that it is made clear to referrers that there remains the ability to specifically request a referral and appropriate escalation pathways should be in place where referrals have been returned with advice despite the GP requesting specialist review.’

It added that the current advice functionality within e-RS is ‘not fit for purpose for the referral of patients’ and it does not integrate ‘effectively’ with primary care clinical systems, often leading to ‘additional requests and demands’ of GPs.

It said: ‘[It] does not create clear paper trails for the purposes of keeping patients informed and in control of the process as would be the case for direct referrals.

‘There is a national update to the e-RS functionality to support a more streamlined process but these will not be available until July 2026 at the earliest.’

The LMCs requested an ‘urgent time-limited pause’ to the plans, and said that there should be:

• ‘Clear differentiation’ between advice and referral intent including escalation pathways where GPs disagree with the SPoA triage outcome, supported by national guidance
• Identification of future target specialities and proposals for co-designed pathways with local GP involvement
• Patient-facing communications regarding locally implemented pathways

North West London Acute Provider Group told Pulse that it has now agreed to ‘pause any further rollout’ following the LMCs’ concerns.

A spokesperson for the North West London Acute Provider Group told Pulse: ‘In April, in line with national policy, we began to pilot combining GP advice and referral requests in e-RS for five services. The intention is to streamline processes so that GPs and patients get the specialist input they need as quickly as possible.

‘However we have clearly not managed to do this as effectively as we would have liked, and we have paused any further roll out and asked our local LMCs to help us review and improve our advice and referral workflows, whilst we await improvements to the national e-RS system. We are committed to building stronger partnerships with all our GP colleagues to help improve health and care more generally.’

Dr Hannah Theodorou, medical director for North West London at Londonwide LMCs, told Pulse: ‘It is important that pathways are co-designed with the input of general practice, particularly ensuring that GPs retain their autonomy to refer patients where clinically indicated.

‘We look forward to working the NWL Acute Provider Group as part of the rapid review to support safe and effective pathways for patients and GPs, established in response to our letter.

‘We recognise the challenging timelines that trusts are working towards, despite eRS functionality not yet being in place to effectively support this programme, but this does not diminish the importance of collaboration with general practice.’

NHS England has recently clarified that GPs are not mandated to use A&G and will not be in breach of contract if they refer directly instead.

It comes as the CQC, GMC and HSSIB asked NHS England for ‘clarity’ on 11 areas related to A&G including a clearer articulation of A&G, GP indemnity, and patient safety implications.

Last month, Pulse revealed that one trust has moved to stop consultants refusing patient referrals from GPs by downgrading them to A&G.