Hospital trust stops consultants refusing GP referrals by downgrading to A&G

Exclusive A hospital trust has moved to stop consultants refusing patient referrals from GPs by downgrading them to advice and guidance (A&G).

Manchester University NHS Foundation Trust (MFT) joint chief medical officer Dr Sohail Munshi was speaking at Pulse LIVE London last month when he said ‘no consultant is allowed to decline a referral’ at his trust.

In his talk, focused on health inequalities and devolved health in Greater Manchester, the former GP partner said better communication at the interface of primary and secondary care is ‘how you will close health inequalities’.

And, referring to advice and guidance (A&G), he said: ‘We adopted some principles for advice and guidance. Principle number one, no consultant is allowed to decline a referral. We just adopted it as a trust.’

Dr Munshi clarified to Pulse this related to a gastroenterology pathway pilot ‘codesigned’ with local GPs and Manchester LMC but he said it was ‘an ambition going forwards’ for this rule to be extended to all specialties.

‘And do you know what, less than 1% of our advice and guidance is returned to us by GPs going, “No, we want you see the patient”,’ Dr Munshi said.

The imposed 2026/27 GP contract scrapped the £20 A&G service payment that GPs could claim and embedded that funding (worth £80m) into the core GP contract.

The contract also included plans for a consultant-led single point of access to ‘divert’ 25% of GP referrals back to GPs for 10 ‘high volume specialties’ from October this year. However, NHS England has since rowed back on this, writing to GPs to deny there is a national target.

Explaining the Manchester gastroenterology pathway pilot to Pulse, Dr Munshi said: ‘The gastroenterology team include an email contact with advice and guidance so a GP can choose to still request a face to face appointment without a further referral,’ he said.

‘Analysis of the first 100 or so referrals showed only one such conversion, allowing a better service for patients and better satisfaction for GPs and consultants. The numbers are sustained a few months on and so any conversions have been easily seen in 1-2 weeks as they are so low.’

According to Dr Munshi, problems with the interface between general practice and hospitals are ‘very fixable’ by improving collaboration.

He said: ‘We are, one pathway at a time – with a combination of GPs and consultants – agreeing what the pathway looks like, rather than falling out over advice and guidance and who has what.’

He also said that when GPs disagree with a referral returned as A&G, the trust pledges to see the patient within 10 days.

He said: ‘We adopted this principle that if we give you advice and guidance and you [GPs] think, “No”, then you don’t write back to us. You just have a single point of electronic access that says, “No, see the patient face to face”, and our offer is we’ll see them in the next 10 days.

‘It is the best thing we’ve ever done as a trust.’

Dr Munshi also challenged GPs concerned about inappropriate workload transfer to ensure they make contact with hospitals.

He said: ‘If you say to me that your hospital just won’t talk to you, I am going to challenge you back and say, “Have you actually recently emailed them and said we’d like to get into a dialogue about this?”. And I don’t mean the LMC. You don’t need to send them an inappropriate workload. That’s not how you communicate.

‘Because I’ll tell you now, nearly every hospital trust medical director that I meet also asked me the question, “How do I speak to GPs?”’.

Dr Simon Minkoff, chief executive of Manchester LMC, told Pulse ‘any initiative by hospitals to listen’ to GPs was ‘to be welcomed’.

Dr Minkoff told Pulse: ‘GPs are becoming increasingly frustrated with government initiatives and pronouncements that increase obstruction to good patient care. We are not adequately resourced to deliver increasingly frequent and complex consultations in lieu of specialist care.

‘Every referral converted inappropriately to A&G sadly diverts GP time from core GMS patient care to responding and challenging the system. This is not good for patients and this is another nail in the coffin for general practice. 

‘When general practice cannot deliver its core GMS commitment patients suffer and hospitals struggle too. So, any initiative by hospitals to listen to and respect the expert opinion of local GPs making access as obstruction free as possible is to be welcomed.’

Last month, NHS England has wrote to GPs to deny there is a national target for referrals being sent back to general practice, and said that requests for referral or specialist advice must now receive a response ‘from a named consultant’.

Greater Manchester ICB and NHS England declined to comment.

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