There will be no national mandate for GPs to use advice and guidance in a certain number of cases, NHS England has told Pulse.
National medical directors for primary and secondary care said that formalised pathways should be developed ‘locally’, and decisions should be based on an area’s population.
In September, it was reported that NHS England’s upcoming outpatients strategy would further increase the use of advice and guidance (A&G) before GP referrals are accepted, with the RCGP then ‘voicing concerns’ about this proposal.
However, when asked about the reports that this would be mandated, Dr Stella Vig, national medical director for secondary care and clinical director for elective care, said she ‘doesn’t know’ where that came from, and ‘doesn’t recognise’ those comments.
NHS England also released guidance clarifying the medico-legal risks and clinical responsibility for clinicians using A&G or referral assessment services (RAS), which is now available on the NHS Futures website.
The guidance, published yesterday, said that these forms of specialist advice are ‘expanding rapidly’ as a result of improvements to digital services.
On legal issues, it said liability ‘will be determined on a case by case basis’ but that GPs could be liable if ‘all relevant clinical information is not provided’ when sending an A&G request.
But specialists at hospitals would be accountable if they send back advice to the GP which is ‘not clinically appropriate’ or if they ‘refuse to accept a patient’.
On turnaround times, NHS England has said that ‘local variables will ultimately dictate the agreed response times’ for hospital teams dealing with A&G – but the guidance recommends that the response time ‘should not exceed 10 working days for routine requests’.
In order for A&G requests to be triaged in a ‘timely fashion’, NHSE said there should be ‘appropriate job-planning and resourcing for both providers and referrers’.
National medical director for primary care Professor Claire Fuller told Pulse that resourcing and capacity in general practice is a ‘much broader conversation’ and is not just about A&G, saying the primary care recovery plan will help to ease demand on practices.
‘[A&G] isn’t about putting on extra capacity – this is about actually continuing to do the changes that we’ve already started in terms of modernising the way we deliver care,’ she said.
Professor Fuller confirmed that any funding for GP practices to complete advice and guidance is ‘absolutely for local decisions’ rather than for NHS England.
Last year, Pulse reported that Tower Hamlets LMC had successfully negotiated with local commissioners to be funded £19 per A&G episode in order to deal with the extra workload.
On whether A&G or RAS would be mandated nationally, Professor Fuller said: ‘No, because it would depend on your geography, demography, and topography, wouldn’t it?
‘It would depend on your population. So it’s very hard to do that.’
She added: ‘Those are the kind of things that will work best by locally evolving through the relationships.
‘But that’s the importance of data. My big thing is always “give clinicians data, and leave them alone to make things better”. But you’ve got to make sure you’ve got the right people in the room.
‘So if you compare practice referrals for different pathways, for different things, it’s one of the quickest ways of identifying the unwarranted variation and that we’re doing things completely differently, and that we might then want to evolve a more standardised pathway.’
Dr Vig added that both directors want to focus on ‘clinical conversations’ that are ‘not based on performance metrics’.
‘We need to now just make sure that we talk about people, not about numbers – there’s a real risk that we continue to talk about numbers’, she said.
Pulse’s recent analysis of how A&G is being used across the country found that GPs are concerned about the increased workload it brings, the medicolegal implications, and the lack of resourcing in primary care.
Earlier this month, NHS England published guidance on MSK ‘referral optimisation’ encouraging use of a triage system which explicitly allows rejection of GP referrals.
And in guidance published last month, NHSE recommended A&G as the ‘front door’ to all dermatology services.
Professor Fuller, a GP who produced a landmark review on how to integrate primary care with other NHS services, was appointed to her NHSE role in August, succeeding Dr Nikki Kanani.
READERS' COMMENTS [5]
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An advice and referral system, which many of us have been advocating for many years, gives patients choice and significantly reduces the time for a GP to get specialist advice. It is as follows: A request is sent to a specialist laying out the clinical problem the patient has. The specialist can send back advice (up to 65% of these referrals), typically within a week rather than months on a waiting list with deteriorating health or now increased risk of death. Of the remaining 35% of referrals, significant numbers can go straight to test. This is probably the greatest innovation that if implemented across England could have a dramatic impact on the dreadful and growing waiting list. Patients get specialist input in under a week, GPs get immediate support, the waiting list is reduced and so is the pressure on GPs to manage patient care that should be managed by specialists. This is why I recently got together a group of innovative clinicians from all sector with the Chair of NHSE to argue the case for “advice/referral”. PS: in our system it resourced and template referral (Like 2 week referral forms) have been developed for all specialties. Why not everywhere?
sam everington
The A&G system has been deisgned as a barrier to patients accessing seocndary care, in a desperate attempt to bring wating lists down. That is all.
Best continuity of care provided was by single handed practitioners. They are rare breed now. Group practices should have equal number of patients allocated to each gps . Pt will be seen by that gp almost always barring holidays and sickness.. reception to book patient with same gp if possible. Now we do have problem of new generation of some gps who don’t work 5 days a week.. No nights, ‘no weekends, no work on bank holidays and part time gps makes it difficult to have continuity of care. Less. hours leads to working under extreme pressure in limited time allocated.
Malcolm is right. It’s an obstruction to care that It helps massage the waiting lists.
It shoves huge amounts of work and clinical risk onto GP’s.
The problem is that Sam’s qualified support for a fully resourced and templated Advice /Referral system is interpreted and implemented by NHSE HMG Treasury et al as support for A&G as a defacto barrier to GP referral.
What is described by Sam is not even close to how A&G is implemented in many areas.