GPs urged to challenge ‘mandated’ A&G amid patient safety concerns

A group of LMCs has urged GPs nationwide to challenge any mandated use of advice and guidance (A&G), amid concerns that it could introduce safety risks for patients.  

Wessex LMCs, which represents three LMC areas in the South West of England, said the single point of access policy that NHS England has asked trusts to put in place will mandate A&G ‘in practice’. 

While Wessex LMCs said it supported A&G ‘as voluntary tool’, the single point of access would make it ‘something fundamentally different’ and could risk delaying diagnoses for urgent and serious conditions.

NHS England first began a move to the potential mandating of A&G in 2022, when it said it should be the main referral pathway for access to dermatology services.

And from April, practices will be contractually required to use A&G across specialities ‘prior to or in place of a planned care referral where clinically appropriate’, but the BMA is currently getting legal advice on this amid fears that the requirement could remove GPs’ right to refer.

GPs report ‘inconsistent response times’ when using A&G, ‘conflicting’ specialist advice, and ‘important’ clinical concerns being overlooked, according to Wessex LMCs.

It comes after Pulse revealed GPs in Hampshire, which Wessex LMCs represents, 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. 

The LMCs said: ‘Once single point of access is implemented in a specialty, all other referral routes are closed – there is no alternative pathway. When a GP remains concerned, the steps available to them – and who carries clinical responsibility in the interim – are not clearly established. 

‘NHS England does not describe this as a mandate. In practice, once single point of access is implemented, it is one.’ 

They said that A&G ‘depends on GP judgement about when it is appropriate’ and that effectively making it mandatory ‘removes that safeguard’, and added that specialists responding usually have no prior knowledge of the patient, cannot examine them, and may have limited access to their medical history.

And they called on LMCs across England to make their position on this mandate clear to their ICBs, to NHS England, and publicly, while there is still time to influence its implementation. 

They said: ‘GPs may find themselves unable to refer directly even when specialist assessment is clinically necessary.

‘GPs in our region have described a case where an urgent cancer concern was converted to an advice and guidance response rather than accepted as a referral, and had to be raised more than once before a diagnosis was made.

‘Where advice and guidance replaces urgent referral, there is a real risk of delayed diagnosis with serious consequences for patients.’

They also argued that there was ‘insufficient evidence’ that mandatory use of A&G reduces demand on specialist services and instead ‘adds administrative burden without clear evidence of benefit’.

Wessex LMCs asked NHS England to publish the ‘clinical evidence base supporting mandatory A&G’, a full assessment of patient safety risk for each affected specialty, and funding for the additional workload created for GP practices. 

Pulse has contacted NHS England for comment.

NHS England’s director of primary care Dr Amanda Doyle previously said that ‘there will be nothing that removes the right of GPs to refer’ in the new contract changes.

But she added 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 will need to be agreed with local GP practices first.

A&G requests have risen significantly in the last year, but the Government’s ambition that this would divert two million requests from elective care looks set to be missed.