Reliance on A&G risks diagnosis delays and fragmentation, says RCP

Greater reliance on advice and guidance (A&G) can lead to delays in diagnosis and unnecessary referrals, the Royal College of Physicians (RCP) has warned.

The RCP has criticised over-reliance on A&G saying that it will not solve issues with fragmentation between primary and secondary care, in a new report on neighbourhood health.

It also said that over half of the physicians who reported providing advice and guidance in a recent RCP survey ‘did not have dedicated time in their job plans to do so’, highlighting the ‘lack of capacity in the current model’.

It comes as GP practices 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 against the imposed contract and is also seeking legal advice on the new requirement, amid fears it removes GPs’ right to refer.

The RCP warned that greater use of A&G could cause delays, especially for patients with multiple health conditions, and that the neighbourhood health model which the Government has committed to ‘will not work if it simply transfers hospital activity into community settings’.

The report said: ‘Greater reliance on advice and guidance, coupled with a lack of joint decision making between professionals about when specialist input is needed, can lead to delays in diagnosis or unnecessary referrals.

‘These delays particularly affect patients with multiple health conditions or complex needs, whose symptoms can be harder to assess remotely and who require earlier medical specialist involvement in their care.

‘Neighbourhood care should mean that physicians are involved earlier in patient journeys, offering clear clinical direction at the outset and reducing reliance on repeated requests for specialist advice.

‘Without a clearly defined role for planned specialist care in neighbourhood health, and the conditions required for it to be fully embedded, fragmentation between primary and secondary care will persist.’

The report also said that ICBs need to set out clear plans on how GPs and specialists will work together as part of the neighbourhood health model, among other recommendations (see box).

Local systems should define ‘clear clinical responsibilities’ as part of the new model, including at which stage in a patient’s journey direct specialist input is required, it added.

The report said: ‘To ensure that planned care pathways are clinically robust and workable in practice, any new models of care should be co-designed by physicians, GPs and wider MDTs, with explicit agreement on when medical specialist oversight is needed, who holds clinical risk at each stage and the triggers for escalation.

‘This level of clarity is particularly important for patients with multiple health conditions, frailty or unstable conditions, who may move frequently between community and hospital-based care.’

RCP clinical vice president Dr Hilary Williams said: ‘Neighbourhood working offers significant potential to deliver the reformed approach to planned specialist care that the RCP has long advocated for, but it will only be successful if it brings together the professionals that patients need for safe and effective care – medical specialists alongside primary and community expertise.’

Pulse has contacted the Department of Health and Social Care and NHS England for comment.

NHS England has recently written to GPs to deny that there is a national target for referrals being sent back to general practice, and said that requests for referral or specialist advice must now receive a response ‘from a named consultant’.

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. 

And NHS England guidance, seen by Pulse and marked as ‘sensitive’, said that A&G will be ‘consultant-led, multi-professionally delivered clinical review of general practice enquiries and referrals’, which has left some GPs concerned non-doctors could be asked to review and respond to requests.