A&G ‘is not mandated’ and direct referrals can’t lead to GP contract breach, says NHSE
GPs are not mandated to use advice and guidance (A&G) and will not be in breach of contract if they refer directly instead, NHS England’s national medical director has said.
Professor Francesca Swords’ comments came as she answered questions during a public Q&A at NHS England’s board meeting last week – including one on whether it was ‘appropriate to mandate A&G in any form’ while the Health Services Safety Investigations Body (HSSIB) is investigating the patient safety risks of doing so.
GP practices in England are required under this year’s 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.
However, Professor Swords said that there is ‘still confusion in this area’ and that advice and guidance ‘is not and has never been mandated’.
She also said that secondary care converting a GP referral to A&G should ‘directly’ inform the patient of the rejection.
Professor Swords said: ‘I’m sorry that there is still confusion in this area, but advice and guidance is not and has never been mandated. The HSSIB has also clarified that point, which I hope is helpful.
‘The current position is that practices are expected to use advice and guidance prior to or instead of a referral if clinically appropriate, alongside sending traditional referrals if that is clinically appropriate.
‘So this is an “and”, not necessarily an “or”, advice and guidance will support that clinical decision making. It does not override it, and it does not remove the clinician’s responsibility to refer where that referral is in the best interest.’
Asked if a GP making a direct referral instead of seeking specialist advice would be in contractual breach, she said: ‘The board can confirm that the contractual requirement is qualified by clinical judgment.
‘Where a GP determines that direct referral is clinically appropriate, that would not be a contractual breach, that is absolutely the right thing to do.’
‘This is consistent with NHS England’s letter of the 22 of April, which is again clear that the clinical threshold for referring for referral is under is unchanged, and this is an additional choice of different a different route, not instead of.
‘Advice and guidance should be used where clinically appropriate and in line with notified pathways, but it is not intended to cut across clinical judgment by GPs and is not a mandatory prerequisite to referral.’
She added that there is ‘no expectation’ that GPs must provide a separate formal justification for deciding whether they are sending a referral or advice and guidance.
Responding to a question on whether Jess’s Rule and the single point of access were ‘consistent with one another’, Professor Swords said secondary care would ‘directly communicate with patients’ when a referral is converted to A&G.
She said: ‘If appropriate, GP teams will refer patients onward for further tests, and that might mean a scan that they could request themselves, or a further assessment, and that would mean taking expert advice from a specialist colleague, either through advice and guidance or referral.
‘Where a referral is converted back to advice and guidance by colleagues in secondary care using that single point of access, secondary care colleagues will directly communicate with the patients so there’s absolute clarity.’
It comes as the CQC, GMC and HSSIB asked NHS England for ‘clarity’ on 11 areas related to A&G including a clearer articulation of A&G, GP indemnity, and patient safety implications.
Last month, Pulse revealed that one trust has moved to stop consultants refusing patient referrals from GPs by downgrading them to A&G.
And LMC representatives from around the UK demanded that Governments ensure any advice and A&G systems ‘are optional’ and do not delay access to clinical care.
