GPs advised to demand consultant’s GMC number when referral is turned into A&G

GPs should demand GMC numbers of secondary care doctors taking responsibility for GP referrals being inadequately turned into advice and guidance (A&G), the BMA has advised.

In new guidance, the union’s GP committee said that any GP referral request turned into advice and guidance must be ‘made by a named GMC-registered doctor’.

It also said that when responding to inappropriate A&G, GPs should mention Jess’s Rule, adding that systems that ‘delay or obstruct referral’ run counter to the rule and introduce a ‘clear and avoidable patient safety risk’.

The GPC also warned that ‘preventing or obstructing referral’ may place doctors ‘in conflict with their professional obligations’ under Good Medical Practice, which states that doctors must ‘refer a patient to another suitably qualified practitioner when this serves the patient’s needs’.

It comes after last week the primary care minister refused to confirm whether only consultants will be able to divert GP referrals to A&G under this year’s changes to the GP contract.

The GPC is threatening GP collective action from 30 April unless the Government ‘pauses’ its plans around mandated A&G, and it is also currently seeking legal advice on the new requirement, amid fears it removes GPs’ right to refer.

However, in an update to GPs, GPC deputy chair Dr David Wrigley said that ‘urgent bilateral negotiations’ with Government are ‘now underway’.

He said: ‘The time has passed for further words of comfort – we need action from our politicians. Urgent bilateral negotiations with Government are now underway and are dependent on securing a commitment that contractual proposals around changes to “advice and refer” services are paused, and mitigations are put in place around unlimited and unsafe same-day care once practices have reached their safe working limits.

‘We know how many of you are struggling with this without any safeguards or resources. Should these conditions not be met by 30 April, we have been clear we reserve the right to immediately escalate to collective action.’

The new GPC guidance said that where a referral is rejected and replaced with A&G that ‘does not resolve the clinical issue’ or ‘requests additional unfunded work’ in primary care, the GPC recommends that practices formally respond to the provider, demanding GMC numbers of the secondary care doctors that will take responsibility for the rejection.

The GPC provided a template letter for practices to use in this instance, which said: ‘Conversion of this referral to A&G without our prior consent is inappropriate and will not be acted upon.

‘Any decision to reject, delay, or convert this referral must be made by a named GMC-registered doctor, with their full name and GMC number clearly stated in the response.

‘In the absence of such identification, we will assume that the Trust’s Medical Director is accepting responsibility for this decision. Any resulting delays in patient care or treatment will be considered the responsibility of the receiving secondary care team.’

And where there are potential issues with patients safety and clinical accountability, LMCs should also step in to write to trusts or ICBs, mentioning the clinical risks of rejecting referrals as well as Jess’ Rule.

Introduced to the NHS last year, Jess’s Rule encourages GPs to ‘think again’ if after three appointments about the same symptoms they have been unable to offer a ‘substantial diagnosis’, or if a patient’s symptoms have escalated.

However, as exclusively revealed by Pulse, NHS England said that even using Jess’s Rule will not give GPs an ‘automatic right’ to refer a patient to a specialist under the new A&G requirements.

The GPC template letter for LMCs said: ‘We are already aware of cases where A&G has been used as the only route for referral, with concerning outcomes. In one anonymised case, a patient referred urgently under a suspected cancer pathway had their referral repeatedly downgraded to Advice and Guidance.

‘Despite persistent symptoms and repeated GP concern, specialist assessment was delayed until a third referral. Cancer was subsequently diagnosed more than nine months after the initial referral.

‘Throughout this period, the patient was not examined by a specialist. This case illustrates that the risks described above are not theoretical.

‘This is particularly concerning in the context of Jess’s Rule, which emphasises the need to reconsider diagnoses and escalate care where patients present repeatedly with unresolved or unexplained symptoms.

‘Systems that delay or obstruct referral in these circumstances run counter to this principle and introduce a clear and avoidable patient safety risk.’

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. 

Under changes to the GP contract for this financial year, GP practices are contractually required 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.

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.