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GPs asked to use ‘advice and guidance services’ to keep patients away from hospitals

GP locked in

NHS England has said it wants to ‘maximise opportunity’ in the management of patients in primary care via advice and guidance services rather than referral.

Last month, health secretary Matt Hancock signalled that he wants GPs to continue to consult patients who would typically be seen in secondary care – with specialist help – after the Covid-19 pandemic comes to an end.

And a recent update to the GP standard operating procedures said GP practices should use advice and guidance services to ‘keep patients away from hospital’, despite messages to restart routine care.

These services involve GPs accessing specialist advice by telephone or IT platforms.

In new guidance on ‘high impact interventions’ published today, NHS England said A&G services would give commissioners ‘greater confidence that referrals into secondary care are appropriate’.

Further benefits of the service are that it allows patients to be ‘managed outside the hospital setting for longer’ and provides ‘improved access to services’, the document added.

However, GPs previously warned that this approach amounted to ‘workload dumping’ and could lead to people being ‘turned away from general practice’ because GPs are too busy dealing with complex patients.

The document added: ‘During the NHS response to Covid-19, A&G services are central to supporting the management of patients in primary care, as well as the restoration and recovery of elective services.

‘Changes to current models of A&G delivery may be implemented at organisational or system level, to maximise opportunity in the management of patients outside secondary care.’

Separate guidance specifically for practices said the service allows GPs to ‘access specialist advice before or instead of referral’. 

It added: ‘This strengthens shared decision-making, enhances personalised approaches to care and avoids unnecessary outpatient activity.’

The GP guidance added that practices should ‘support system partners in implementing A&G services in their area’.

This could include 

  • nominating a ‘clinical champion’ across or within PCNs to support the shaping of A&G services
  • working with CCGs to ‘regularly’ review ‘demand and availability’
  • designing  ‘clear governance arrangements’ such as the retention of ‘accessible records’ alongside CCGs and secondary care partners

Meanwhile, commissioners should ‘facilitate collaboration’ between primary and secondary care, it added.

It comes as a report revealed earlier this month that ending inappropriate transfers of workload from secondary care could free up 3m GP appointments across England.

Throughout the Covid-19 pandemic, GPs have warned that they are managing more patients ‘outside their comfort zone’ due to less support from secondary care services.

And one LMC last month warned NHS England that its local hospital has ‘closed its doors to patients’.

Since April, NHS England has told GPs to continue referring patients to secondary care despite restrictions on elective care due to Covid-19.

Last month, it outlined that trusts must make their e-referral service ‘fully open’ to GPs.


Musharraf Hussain 21 September, 2020 10:16 am

How can GPs give advice and guidance, when in my town, hardly any GPS are seeing patients virtually or face to face? There are no appointments when you ring, no online appointments.

Darren Tymens 21 September, 2020 10:34 am

Now that hospitals are on block contracts, the organisationally-self-interested thing to do would be to push as much existing work as possible onto other providers, whilst retaining the funding.
Advice and Guidance is essentially a way of compelling GPs to deliver the majority of outpatient work without any extra funding or resources to enable it, and without any assessment of what free doctor and nursing capacity exists in practices to deliver it (I will save them the effort, after 15 years of continuous cuts in funding, there isn’t any).
This ‘innovation’ could have been delivered ten, twenty years ago. The only reason it wasn’t was that hospital income under PBR would have dropped very significantly, and the extra resource would have had to have been moved into general practice to deliver it. And so commissioners (who never wanted to risk ‘destabilising the hospitals’ and never seem to want to invest in general practice) sat on their hands and did nothing.
This needs to be very visibly and vocally resisted by the GPC. Alternatively, GPC will have to unilaterally set workload limitations based on the funding we receive, which will not meet patient expectations for access etc.
If NHSE want this, they need to invest heavily in general practice to deliver the new system, and they need to give us time to build proper nursing and doctor capacity – though this may take years due to the effects of neglect.
Otherwise there is a serious risk of collapsing the system, as general practice becomes overwhelmed.

Anthony Everington 21 September, 2020 11:36 am

Interesting – so they want to reduce face-to-face in hospital!

Robert Vaughan 21 September, 2020 1:01 pm

The whole Covid debacle is fascinating. Today Whitty is wittering on that we might be getting 200 deaths a day by November. Perhaps we should tell the population that 1500 people die every day and that ultimately everyone dies because currently every death seems a surprise.

Anthony Everington 21 September, 2020 1:21 pm


Patrufini Duffy 21 September, 2020 2:47 pm

Why would a GP need advice and guidance?It’s called short changing, or responsibility shifting. The gatekeeper wants to open the gate, and you keep closing it in their face.

Christine Paterson 21 September, 2020 9:18 pm

Who caries the medico legal risk package when the music stops . Most definitely NOT the hospital.

John Glasspool 21 September, 2020 9:39 pm

Isn’t this just like the “We’re on black alert: don’t send sick people to hospital”?

David OHagan 22 September, 2020 6:00 pm

When will the resources follow this extra work into primary care?
Which hospital trust is not charging extra for doing this on top of their usual clinics?
Any providers found this reduces their work and prepared to put their cash back into the system?

Andrea Wallace 23 September, 2020 10:42 pm

A&G is a good innovation when GP has a specific question. It’s not appropriate when 2ndary care use A&G to reject a referral with a list of investigations and treatment options. As previous comment states – who is responsible for the patient when secondary care haven’t ‘accepted’ the referral