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GPs should be paid £12.50 per ‘advice and guidance’ episode, says LMC


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Exclusive An LMC has called for GP practices to be paid £12.50 per advice and guidance (A&G) episode to resource the extra workload.

The bid comes amid a national drive to increase the use of A&G to reduce GP referrals to secondary care, by enabling GPs to care for the patient instead of a hospital specialist.

In a letter to Barts Health NHS Trust and NHS North East London (NEL) CCG, sent last week and seen by Pulse, Tower Hamlets LMC said that an audit carried out in August assessed the ‘impact’ of A&G services on practices.

The audit showed that each A&G episode takes each practice 13 minutes ‘on average’ – seven minutes of GP time and five minutes of GP staff admin time – it said.

The LMC has been ‘clear in all discussions that general practice cannot take on extra work unless the resources follow to support it’, it added.

NHS England has set an A&G target across the country in a bid to curb GP referrals to hospitals, which requires GPs to use A&G for 12 out of 100 outpatient attendances by March next year.

But Barts has launched a more far-reaching trial requiring GPs to use A&G services before referring patients, with the potential for this to become a permanent measure.

The letter said that while ‘many’ GPs ‘like the opportunity to manage more complex patients that would normally be seen in secondary care and feel that this enhances their professional development’, the ‘flip side is that managing such patients increases GP workload and the risk we hold’.

It added: ‘We have estimated that the cost to general practice is £12.50 per advice and guidance episode. 

‘We understand that Barts has development money available for this project and assume that general practice will be recompensed for this work from this pot? If not, please could the CCG let us know how we will be paid?’

A spokesperson for NHS NEL CCG told Pulse: ‘We are in regular discussion with our GPs about appropriate funding for work undertaken in primary care and we are currently assessing how they can be best be supported to make greater use of advice and guidance services (A&G).

‘Northeast London clinicians have led the way in adopting A&G during the pandemic and are fully supportive of the benefits. This approach is crucial to getting patients access to the information and support they need, in the most appropriate setting, as quickly as possible.’

Barts Health NHS Trust declined to comment.

Pulse has also approached NHS England for comment.

Tower Hamlets LMC chair Dr Jackie Applebee told Pulse that it is ‘ludicrous’ to expect GPs to take extra work unresourced, especially when they are already ‘drowning’.

She said: ‘It is just ludicrous – as if we’re not drowning. We know the hospitals are under pressure, don’t get me wrong, but there are some things that we could quite easily manage in general practice with a bit of support.

‘But expecting us to take all that on when at the moment we can barely do the day job is ludicrous. It’s just completely mad.’

The push back comes as Pulse last week revealed that another major London CCG has set out an aim to cut GP referrals by 65% across seven major hospital trusts through A&G services.

GP leaders have warned that any measures leading to GPs facing rejected referrals and therefore more ‘unresourced’ work and greater medicolegal risk are ‘unacceptable’.

The LMC said it has been having ‘productive meetings with respect to the national expectation to roll out advice and guidance’.

GP leaders have also previously raised concerns that A&G is yet another form of ‘workload dumping’ from secondary care and cautioned that patient referrals may be declined in error.

READERS' COMMENTS [15]

Darren Tymens 8 November, 2021 10:45 am

It’s a start, but £12.50 is nowhere near enough. We just don’t have capacity to deliver the extra work, especially at marginal levels of funding.
Primary Care needs a programme of major investment in order to improve working conditions and develop capacity. The vast majority of anticipated outpatient savings deriving from A and G should be directly reinvested into the core contract. Every A and G undertaken in general practice saves the system around £250 (because hospitals are absurdly expensive places to deliver most care) – perhaps every A and G undertaken should be funded at £50 to the practice and £150 reinvested into the core contract; that way the system still sees 20% savings and general practice could start to pick itself off the floor.

Kevlar Cardie 8 November, 2021 10:47 am

Would you like a large fries with that ?

Arnold Abraham 8 November, 2021 11:18 am

This should be referred or pointed out to the CQC as invariably patients will suffer in the delay. Also GPs do not have the time to do this well and it will also lead to a delayed referral sometimes, after all the blood results for example. The £12.50 is an insult. It is below the minimum wage and I will kindly decline such generosity.

David Church 8 November, 2021 11:34 am

D Tymens has a better idea.
I agree that the hospital should suffer some retribution for their refusal to see these patients face-to-face; equivalent to the bashing that GPs are getting for seeing patients F2F, but failing to ensure 100% of practices do so at a rate that is higher than the average !
Will the Daily Mail start a campaign to get referrals seen F2F at the hospitals?

Richard Hook 8 November, 2021 12:05 pm

You report the LMC as saying it is £12.50 A&G episode, but you headline says per “session”> I would have thought there was an important difference between the two….I think £12.50 per A&G request is fair….whereas £12.50 per “session” of writing the requests is derisory.

Sally Anderson 8 November, 2021 12:27 pm

£12.50 for a lot of potential work
Yes I’m one of those more experienced GP s who prefers to manage my patients in the primary care setting as much as possible and welcome advice and guidance but to suggest that £12.50 covers the cost both of the initial request for advice and guidance AS WELL AS the actions of putting that guidance into place —— further GP and staff time involved, future monitoring and work resulting from that guidance is I agree a sheer insult

Chris GP 8 November, 2021 1:07 pm

Offering £12.50 is such a small amount – it probably does more harm than good in terms of how valued I feel. I am actually quite happy to do it for “free” – but as I have said before – do expect there to be a delay in delivering the other wants NHSE / patients / The Daily mail have ..as this will be instead of, not as well as all that stuff. There are only so many hours a day I can work, there are only so many days in a week, weeks in a month, months in a year…..NHSE – read my lips….I am full.

Paul Attwood 8 November, 2021 6:17 pm

I recall from some time back a sort of a joke doing the rounds. “How do you get rid of difficult GPs?” Answer apparently was to chuck a penny under a moving bus and see the GPs dive to grab the penny.

How about valuing yourself. £12.50 might just get you a McD’s meal with fries. But for an A&G episode, seriously? That offer needs to be rejected with venom.

In fact the whole A&G saga needs to be examined. When I referred I was as much saying that it was as far as I was prepared to take that clinical episode and help was needed. Insisting that I take it further would put me outside my comfort zone and possibly increase the patient risk.

The job is shit enough without making it worse.

terry sullivan 8 November, 2021 6:45 pm

try and get advice from a solicitor for that?

Douglas Callow 8 November, 2021 8:35 pm

undervalues effort responsibility and risk hugely

Dylan Summers 9 November, 2021 3:18 pm

It’s hard to put a sensible figure on the work when we’re already receiving a global sum etc. But £12.50 doesn’t help make me feel valued.

Simon Sherwood 9 November, 2021 6:22 pm

It’s a start I suppose.
Making people understand that GP time is not free.

Medicolegally, and as a good doctor, If a secondary care doctor gave me advice I knew to be against the patients best interests I have ignored it.
I’ve never regretted this

Finola ONeill 11 November, 2021 11:47 am

A&G just totally misses the point. It is not equivalent care. 2 minutes for one problem in the 10 minute consultation with a letter for advice does not equal a 30 minute review by a specialist doctor with appropriate follow up and investigation. If I know what to do I do it. If I have reached my abilities I refer. Ongoing regular training from specialist teams regarding management can help. That needs long term funding or the time for us to extend our knowledge. part from ongoing practical training throughout our professional lives A&G is not a swap for referrals and specialist care. Medicolegally and clinically i’s not equivalent. I recommend we fully decline all attempts to blur the distinction. Arguments about funding are a distraction. Ditto PCN development. It is also an attempt to off load clinical care onto primary care form secondary care. Whether it is MS team meetings for primary care with psych, chronic pain for the similar “phone a friend” approach to specialist care rather than referrals or care home input from primary care to prevent admissions. It is all a workload dump and one we can’t afford to take on. Burnout alert.

Patrufini Duffy 12 November, 2021 10:23 pm

If you need advice and guidance, go back to medical school. You’re a Consultant in referrals and triage. Get a grip, or get your complaints policy out.

Jamal Hussain 18 November, 2021 11:55 am

The global sum is for core general practice as per the Contract and custom and practice as to what was done at the time of the contract. Taking on secondary care work under the guise of A&G is clearly outwith of what was being done in custom and practice and is new work. The problem is the global sum, which hasn’t increased to match the increased work load and won’t do so. It needs to be binned in favour of an items of service payments system. Which should be realistically valued at inception and increase each year to maintain its value. Those of us who are more hard working and more effective will get paid more. So this will never see the light of day.