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A&G should be main referral pathway in dermatology, NHS England says

A&G should be main referral pathway in dermatology, NHS England says

Advice and guidance (A&G) should be the main referral pathway for access to dermatology services, NHS England has suggested.

In a document setting out the principles for ‘referral optimisation’ for people with skin conditions, the use of ‘pre-referral specialist advice’, such as A&G, followed by specialist triage is advocated as the main referral pathway with the exception of suspected skin cancer.

This will improve working between primary, intermediate and secondary care, the document states, and will ‘facilitate a clinical dialogue’ before a referral is considered.

With dermatology departments prioritising the two-week skin cancer pathway, this has an ‘inevitable impact’ on access for people with inflammatory skin conditions, such as eczema, psoriasis and acne and A&G could help mitigate the long waits they face, NHS England said.

It is estimated that a third of face-to-face hospital outpatient attendances could be saved by 2023/24.

In February, the Government set out its long-awaited elective recovery plan that stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.

Professor Martin Marshall, chair of the Royal College of GPs said they had been clear that this approach must be optional, not mandated, for GPs and their teams. 

‘Whilst the aim of reducing referrals is commendable, GPs will only refer to secondary care once they have reached the end of the clinical pathway they are confident with.  

‘Having the option of asking for advice when unsure of the next step in the treatment pathway is very useful, and GPs and their teams must be allowed to refer those directly to secondary care who need onward management.

‘If every referral ends in an electronic conversation between primary and secondary care, this will only add to the workload pressures in general practice and across the NHS.’ 

It was important to prevent patients being caught between primary and secondary care, he added.  

Dr Selvaseelan Selvarajah, a GP in East London, said he would be very worried about this proposal, which does transfer extra work to GPs and should be fully resourced.

‘A&G should be renamed Advice or Referral in the first place. GPs are expert generalists who train for years so are aware of what they need to do for a patient.

‘GPs refer for three main reasons. Diagnostic uncertainty. Know the diagnosis but further investigations and/or treatment are only available in secondary care. Or the patient would like a second opinion.

‘Advice should rightly be obtained for patients when there is diagnostic uncertainty but there should be a referral option for the latter two reasons. So, overall, whilst advice or referral is a great concept and has many benefits for the clinicians, patients and the NHS, we shouldn’t have a blanket policy of all referrals must be A&G only.’

Dr Hussain Gandhi, a GP in Nottingham, where there have been concerns over the introduction of A&G for neurology, said dermatology was an area where such an approach could work better but systems had to be developed in collaboration with GPs.

‘There are patients where it can be useful but for some patients it can delay their care and it is important to recognise it takes away patient choice.’

In 2019, a number of CCGs in the North East of England decided to require GPs take three photographs using their mobile phones and a dermatoscope and submit those with any referral for skin cancer.

In related news, NHS England has told GPs that patients with ‘a FIT of fHb <10μg Hb/g, a normal full blood count and no ongoing clinical concerns’ should not be referred on a lower GI urgent cancer pathway but should be ‘managed in primary care or referred on an alternative pathway’.


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Please note, only GPs are permitted to add comments to articles

Darren Tymens 11 October, 2022 10:54 am

Most dermatologists tell me you have to see and feel a lesion to be confident of the diagnosis. A and G doesnt deal with the reality of how dermatology (or indeed, medicine itself) necessarily works.
Also, if they want us to spend time taking medical-quality photographs, then they need a contract for it as it isn’t core (a DES perhaps, and this would remain necessarily voluntary); they need to pay for medical-grade photography equipment and training for staff to be able to use it; and they need to pay for the dermatology outpatient appointments which we will essentially be delivering instead of the hospital.
They also need to understand that this will make the delivery of core more difficult, as staff and resources are diverted from delivering general practice to delivering secondary-care dermatology.

Turn out The Lights 11 October, 2022 11:04 am

The perversity of it .They treat GPs like crap for over a decade and now they expect us to save their bacon for free and like it.You can only abuse someone for so long before they leave or fight back.Currently the latter is taking place.It’s a NO from me.

Bonglim Bong 11 October, 2022 12:39 pm

This sounds great – come back when we have 8000 more FTE GPs to manage the current workload and another 2000 FTE GPs for the new workload.

Patrufini Duffy 11 October, 2022 1:32 pm

Advice & Guidance — > AKA —> Wing it and Fob them Off and Cover up for us with Your Name here for the GMC ____ .

David OHagan 11 October, 2022 1:47 pm

NHSE is not negotiating a new contract for GPs they are imposing it one speciality at a time.

General Practice is not funded for specialist dermatology.
ie anything they don’t like the look of on A&G
They are quite happy to encourage patients to come forward,
but sadly they are too busy.
So someone else will have to deal with the increased worry, and complaints.
Not too busy to still be (under)funded as a comprehensive service.
Certainly too busy for any of the money to follow the work.

This follows on from Breast (HSJ), and colorectal (FIT) doing exactly the same.

Dr Doyle at NHSE any chance of explaining when the funding is to be moved to pay for all this extra work?

Patrufini Duffy 11 October, 2022 1:54 pm

Maybe Pulse will soon lock onto and expose the ugly slavery going on with the NHSE cover-up:

Truth Finder 11 October, 2022 3:16 pm

Rather rich saying face to face is best rather than remote consulting. Double standards.

Patrufini Duffy 11 October, 2022 3:52 pm

Public don’t respect a GP hear the same plan from a Consultant. It’s therapeutic ping pong. In other news, Consultants have revelled in their private practice. Let’s not talk about that. You cover up for them.

Darren Tymens 11 October, 2022 5:45 pm

dear @truthfinder (who is presumably not a GP?):
a limited number of relatively trivial or straightforward problems can be safely managed remotely if the clinician is sufficiently experienced and safety-nets appropriately, and the patient is sensible and capable, and happy to do so. some patients actually prefer to manage some things remotely – that’s OK, as long as we can do it safely.
but face-to-face remains the gold standard, and most practices either let patients choose, or suggest face to face when it is most the most appropriate way of assessing the patient and delivering care.
the overwhelming majority of consultations take place face to face now, as they did before covid. the period during covid was an aberration, necessarily forced on us by circumstance – and at the clear instruction of the government and NHS leadership.
in my experience, the majority of dermatologists think it better and safer to see the patient rather than look at a (often poorly taken) small 2D image on a screen. they can then take a proper history, ask relevant questions, assess the patient generally, and get a full view of the rash or lesion.
there is no double standard here.