A&G must be ‘optional’ or it will delay patient care, warn GP leaders from across the UK

LMC representatives from around the UK have demanded that Governments ensure any advice and guidance (A&G) systems ‘are optional’ and do not delay access to clinical care.

They voted in favour of a motion demanding that performance incentives are not achieved through the discharge of patients back to general practice ‘without assessment’.

The motion, debated and passed at the UK LMCs conference in Belfast today, also said that patients should be able to resume their place in the waiting list ‘if the practice disagrees with the advice’.

Dr Jessica Court, from Nottinghamshire LMC, who proposed the motion, said: ‘We do not refer lightly. We refer when our expert clinical judgment, based on a holistic assessment of the patient in front of us tells us that we need specialist input.

‘That is why it is so frustrating when referrals are rejected without the patient ever being clinically assessed. Increasingly, referrals are being diverted into mandated advice and guidance pathways.

‘Whilst advice and guidance can be a useful clinical tool, it must support patient care, it must not be a barrier to access specialist care.

‘These systems are increasing GP workload, delaying patient care and shifting unfunded secondary care work into general practice in a way that is unsafe and unsustainable.

‘Too often, the specialist advice that we receive is poor quality. Sometimes it’s not even a fully formed sentence. Yet the responsibility falls back onto the GP to communicate it to the patient, arrange investigations, prescribe treatment and manage the ongoing clinical risk.’

The conference also passed a motion noting an increasing number of letters from secondary care, such as referral rejections and clinic letters, signed by generic titles, such as ‘on behalf of the department team’, creating a lack of clinical accountability.

It called for all correspondence from secondary care, including referral rejections, to ‘include the name, job role and department of the attending clinician’.

Proposing the motion, Dr Pranav Lakhani, from Liverpool LMC, said: ‘Doesn’t it paint a picture of the current state of the NHS that we are even here debating this?

‘We need accountability in healthcare. Especially at a time when we no longer know all of the people working in our local hospital. It used to be the case that you knew the consultant and the relevant teams in each speciality.

‘However, nowadays, with the expansion of consultant numbers and different healthcare professionals working in each of their teams, it’s impossible to know who rejects referrals.

‘No one in this room will have escaped the pleasure of dealing with these. The situation is made much harder when you don’t even know who has rejected your referral and who made the sometimes rather dubious clinical decision behind it.’

GPC chair Dr Katie Bramall told the conference that advice and guidance does not exist in Wales, but the NHS Wales planning framework for 2026-29 contained ‘a performance target for health boards of 20% referral rejections’, and that the BMA has spoken against this target.

In Northern Ireland, the BMA raised ‘serious concerns’ with the Strategic Planning and Performance Group (SPPG) around A&G, and was told that where advice and guidance has been actioned and the assessing GP deems an onward referral is still required, the normal referral process will apply, Dr Bramall said.

Advice and guidance also doesn’t operate in Scotland, but Scottish GPs are seeing ‘increasing cases of inappropriate barriers to referral attempts’, Dr Bramall added, so the Scottish GPC is ‘pushing back strongly’.

It comes as GP practices in England are now required under the 2026/27 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.

This further normalises the practice of GPs taking a wider responsibility for formerly specialist services, with the rollout having started in earnest in 2022, when NHSE said it should be the main referral pathway for access to dermatology services.

The BMA’s GP committee is currently coordinating collective action in England against the imposed contract and is also seeking legal advice on the new requirement, amid fears it removes GPs’ right to refer.

Pulse previously revealed that GPs had raised concerns about specialists downgrading their cancer referrals to A&G, creating a risk of missed diagnoses. Pulse was told that this was happening for cancer referrals to specialties including dermatology, gynaecology, lower GI, urology and respiratory.