GPs’ role in tackling the NHS hospital backlog will focus on the use of ‘advice and guidance’ (A&G), the long-awaited elective recovery plan has suggested.
A&G services involve GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation – with PCNs due to be incentivised for doing so through ‘Investment and Impact Fund’ points worth £9.9m.
The plan for tackling the elective backlog caused by Covid, published by NHS England today, said that GP access to A&G will be ‘expanded’ in line with the PCN incentive scheme announced in August.
It also warned that the waiting list for elective care is set to continue growing for the next two years.
It said: ‘Primary care access to specialist advice and guidance will be expanded through continued engagement and support to primary care networks including £10 million through the Investment and Impact Fund, a scheme focused on supporting primary care networks to deliver high-quality care to their populations.’
A&G could be used by GPs ‘prior to or instead of’ making a referral, or specialists can also ‘review the clinical information and provide advice on the most appropriate next steps without the patient having to wait for an appointment’ after a GP has made a referral, NHS England said.
The report added: ‘This will be further supported by the ongoing development of the NHS e-Referral Service to enable the sharing of images to support clinical teams to undertake more effective triage, while improving patient experience.’
This will include the ‘accelerated adoption of teledermatology services to increase access to specialist advice for suspected skin cancers’, such as further funding so that GPs can take high-quality photos of suspicious moles and lesions and seek specialist cancer advice, it said.
The plan reiterated a goal to ‘deliver around 30% more elective activity by 2024/25 than before the pandemic, after accounting for the impact of an improved care offer through system transformation and advice and guidance’.
GP targets for ‘advice and guidance’
Under the PCN Investment and Impact Fund (IIF) scheme for 2022/23, announced in August, networks will be incentivised to improve their use of A&G.
They will be measured against a target of 6.6 to 19 ‘specialist advice requests per 100 outpatient first attendances across twelve specialties identified for accelerated delivery’.
These specialties are: cardiology, dermatology, gastroenterology, gynaecology, neurology, urology, paediatrics, endocrinology, haematology, rheumatology, respiratory, and ear, nose and throat.
NHS England said at the time that the indicator, which accounts for 44 IIF points worth £9.9m, will ‘support the wider NHS recovery of elective care services through avoidance of unnecessary outpatient activity’.
NHS England has also set out other A&G targets, although these are not backed with incentives.
New planning guidance for 2022/23, published on Christmas Eve, said systems must deliver ‘16 specialist advice requests, including advice and guidance (A&G), per 100 outpatient first attendances by March 2023’. It remained unclear how many of these requests should be GP A&G requests.
In October, GPs were told they must use A&G for 12 out of 100 outpatient attendances by March this year.
The recovery plan, which sets out actions over the next three years, also said NHS England will ‘[work] with GPs to avoid the need for an onward referral where possible’.
However, an accompanying letter added that the impact of the pandemic is ‘not limited’ to elective care and ‘can be seen across mental health, primary and community care’.
‘It will be important to give these areas the same focus as elective care, and for the challenges in these areas to be tackled in unison,’ it said.
It stressed that the NHS workforce would need to be ‘supported’ to deliver recovery targets and that tackling the backlog alongside additional demand including in primary care will be a ‘multi-year challenge’.
It said: ‘The overall size of the waiting list is likely to increase, at least in the short term. If around half the “missing demand” from the Covid-19 pandemic returns over the next three years, particularly if this is earlier in the period, then we would expect the waiting list will be reducing by around March 2024.’
However, ‘any solutions for tackling the Covid-19 elective backlog cannot rely on making the same staff – whether in primary, secondary or community care – work ever harder,’ the report added.
Central North Leeds PCN clinical director Dr Richard Vautrey, assistant secretary of Leeds LMC and former GPC chair, told Pulse: ‘There is a real need for the Government to take the backlog in general practice seriously, as it’s having a major impact on both access to care for all patients and the wellbeing of all those working in general practice trying to do their best to deal with both this and the wider implications of the secondary care backlog on practice workload.’
The plan set out targets to:
- Eliminate waits of over one year by March 2025 and waits of over two years by July 2022, acknowledging that some patients will choose to wait longer and there will be ‘challenges’ in particular specialties as before the pandemic;
- Reduce diagnostic waiting times, with the aim of least 95% of patients receiving tests within 6 weeks by March 2025;
- Deliver the ‘cancer faster diagnosis standard’, with at least 75% of urgent cancer referrals receiving a diagnosis within 28 days by March 2024 and return the 62-day backlog to pre-pandemic levels by March 2023.
- Better ‘monitor and improve’ both waiting times and patients’ experience of waiting for first outpatient appointments over the next three years
It also revealed that:
- A framework to ‘support the review of patients on the waiting list for an outpatient appointment’ is due to be published by March 2022.
- NHS England will ‘work closely with general practice teams’ on support for those who have been waiting a long time for treatment.
- Patients waiting for elective care should be given ‘correct information on decision-making and support offers’ to avoid placing ‘additional strain’ on primary care.
- Patients should be assured it is ‘appropriate and safe’ to be discharged to avoid placing ‘unnecessary demand on general practice from patients attending with outstanding concerns’.
- ‘At least’ 100 community diagnostic centres are planned to be in place over the next three years, with 66 by the end of 2021/22 and an ambition to reach more than 160 across the country.
- The UK Health Security Agency (UKHSA) is ‘continuing to consider ways in which IPC can safely be returned to as close to pre-pandemic conditions as possible’ so that recovery is not slowed by ‘unnecessary stringent measures’.
Health secretary Sajid Javid had promised the Government would publish its plan on how to tackle the elective care backlog by the end of November, but said last month that it would finally be published ‘in the next few weeks’.
Trailing the plan yesterday, the Government announced that patients on the NHS elective wait list will be given online support to help them get fit for surgery and keep them up to date regarding waiting times.
It was also announced that perioperative support teams ‘made up of nurses, care-coordinators and doctors’ would be in place from April 2023.
Meanwhile, Pulse revealed in November that an LMC has called for GP practices to be paid £12.50 per A&G episode to resource the extra workload.
It followed a major London trial assessing advice and guidance as the single point of access for referrals and a CCG target to cut GP referrals by 65% through A&G.
Also in November, GP leaders demanded an end to hospitals being allowed to mandate the use of A&G before accepting GP referrals of patients to secondary care at the LMCs Conference.
READERS' COMMENTS [4]
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This is the most idiotic target in history.
1 – GPs will quite rightly harden their stance about doing work dumped on them through this scheme. so A+G comes back requesting test a, b and c – I think i will just refer saying the advice was to do test a b and c, this is not the job of primary care, off you go.
2 – GPs who need to hit the target will just increase A+G for simple things, like sending A+G to rheumatology every time there is someone with slightly lower vit D – and they can reply with take some vit D otc and I’ll be able to tick the boxes for enough A+G requests.
3 – Most importantly of all it penalises GPs who either learn or are particularly skilled.
So GR Dr Dumb does A+G every time he gets complex haematology results. And gets rewarded for it. GP Dr Smart does it the first time, learns what to do and then manages the pateints more independently – but gets penalised for it.
Never going to happen unless the pension debacle is finally sorted.
Although I agree with our colleague Dr Bong that the target is idiotic, i don’t think it qualifies as the most idiotic in history because there is, frankly, quite a lot of competition.
I do think that it risks generating lots of pointless exchanges and therefore extra workload: measuring anything always changes behaviours.
I also think the risk – in fact the purpose – of this is to shift workload out of hospitals, but without the funding necessary to deliver the extra capacity required to undertake the workload (so, similar to the ongoing online consultations fiasco).
I know LMCs are pushing back hard on this (DOI I am an LMC MD), but there are three things we need to take away:
1) practices need to recognise workload dumping and send it back to the consultant, who is funded to deliver the care.
2) the GPC Exec needs to put this on the table during the current contract negotiations, and either refuse it or negotiate proper renumeration (I would start at 70% of the value of a typical OPA under PBR for every A+G actioned in primary care, so around £175; the current offer appear closer to 15p per patient per year)
3) we need a new contract that explicitly links funding to workload, to stop ICSs overwhelming us with their problems
You remember that plaquard on the wall: “Follow your Gut”; “Do no harm”. If you haven’t learnt when to refer, you need a new job, because that is your job. Sitting their lonely, with a pad of dusty paper, free stethoscope from 1992 and a dubious temperature probe. Being a hero. Saving resources.