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Major London CCG sets target to cut GP referrals by 65% via ‘advice and guidance’


NHS Digital 111


Exclusive A London CCG has set out an aim to cut GP referrals by 65% across seven major hospital trusts through ‘advice and guidance’ (A&G) services, Pulse has learned.

NHS North Central London (NCL) CCG, which covers a population of 1.6 million patients, said this would avoid ‘unnecessary’ patient visits and reduce ‘inappropriate referrals’.

The trusts include both the Royal Free London Hospitals and University College London Hospital (UCLH) NHS foundation trusts.

A&G involves GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.

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

Pulse has learned that NHS North Central London CCG is currently procuring an ambitious new A&G service to connect GPs and hospital specialists via calls and text messages across the area, with the successful provider to be measured against ‘key metrics’, including downgrading 65% of GP referrals.

A service specification, seen by Pulse, said that the ‘percentage of calls avoiding a referral/hospital admission’ and the ‘percentage of messages avoiding a referral’ should both be ‘at least 65%’.

Meanwhile, the procurement notice for the new contract, published last month, said it is expected to begin on 1 April 2022 with a ‘possible deadline for delivery’ of 31 March 2027.

The CCG said the procurement follows a successful A&G pilot during the Covid pandemic.

‘Evidence has shown that approximately 60% of calls avoid a referral or an admission to a specialist service,’ it added.

The procurement notice for the new service specified ‘a digital platform to enable both telephone-based and clinically secure photo messaging application for the provision of clinical advice and guidance for a range of clinical specialties.’

The documents said it must:

  • cover both physical and mental health, backed by a ‘national network of NHS clinicians’ available seven days a week so that primary care ‘always has access to immediate clinical advice and guidance’.
  • cover urology, orthopaedics, rheumatology, renal medicine, paediatrics, neurology, haematology, gynaecology, general medicine, gastroenterology, elderly care, ENT, diabetes and endocrinology, cardiology, dermatology, ophthalmology, HIV and mental health.
  • include a ‘virtual hospital to manage patients between primary and secondary care’.

According to the CCG’s notice, ‘benefits’ of the service would include a ‘better’ experience for GPs, consultants and patients.

GPs will have ‘improved patient management including patient episodes [concluding] with no follow-up work [and] casebased learning’, while consultants will see a ‘reduction in inappropriate referrals’ and in ‘the number of written requests for advice that require responses’, it said.

Meanwhile, patients will gain ‘improved access to [the] clinical care pathway’, an ‘avoidance of unnecessary patient visits to hospital’ and a reduction in ‘follow-up visits to GP practices’, it added.

And, in response to medico-legal concerns, calls will be ‘recorded as highly-encrypted, information-governed digital files which provide a medico-legal record that is available to the relevant GP practice and hospital team’, the service specification said.

It will be up to GPs to ‘discuss/agree’ this with their patient ahead of the call or message, explaining that the advice will be stored as part of their medical record.

Following each A&G call, GPs will be asked to ‘rank’ the outcome, while the consultant will receive a text message asking them for ‘their view of the call outcome’ where GPs ‘fail to rank a call’.

‘At least 90%’ of GP feedback on the service should be ‘good or very good’, said the specification.

The news comes as another major hospital trust, in East London, has launched a trial requiring GPs to use A&G services before referring patients, with the potential for this to become a permanent measure.

It also comes as NHS England has already 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.

Medical Defence Union (MDU) medicolegal adviser Dr Ed Nandasoma told Pulse that GPs are responsible for ensuring any referral – including via A&G – includes clear and appropriate information, while consultants are responsible for deciding what action is taken.

He said: ‘Any GP making a referral – via A&G or any other route – will be responsible for ensuring that appropriate information is included in the referral and that the matter on which advice or guidance is being sought is clearly communicated.

‘The responding clinician will be responsible for reviewing the information provided and taking a decision as to whether to offer advice, ask further questions if more information is required, seek the referrer’s agreement to covert the A&G request to a referral or to suggest an alternative route of care where that is more appropriate.’

However, Dr Nandasoma added that GPs who are ‘concerned that their patient may not be seen as soon as they might have been in the past’ should consider communicating ‘clearly’ in the referral if there are ‘urgent clinical concerns’.

They should also consider ‘explaining to patients the timescale in which a response is expected’ and ‘giving and documenting clear and specific safety netting advice on what the patient should do if their condition deteriorates’.

Medicolegal consultant at Medical Protection Society (MPS) Dr Karen Ellison told Pulse that practices must ensure patients ‘do not slip through the net’ and that they have ‘accurate and clear documentation’ in place for use in any medicolegal defence.

She said: ‘It is vital for practices to ensure that there are reliable systems in place to follow up on referrals so that patients do not slip through the net. 

‘The cornerstone of any medicolegal defence is an accurate and clear documentation, which often may need to be relied upon years after the consultation or clinical incident.’

An MPS survey earlier this year found that nearly four in five UK GPs (77%) are ‘concerned about facing investigation if patients come to harm as a result of delayed referrals or non-Covid-19 services being unavailable or limited’, she added.

GP leaders have 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 [14]

Darren Tymens 4 November, 2021 10:22 am

We should stop calling it ‘cutting referrals’ and start referring to it as ‘shifting clinical workload into general practice.’
If this is about improving care (the usual justification) rather than improving profit margins (the usual motivation) in hospitals then the 65% of outpatient costs saved should be shifted into general practice to fund the delivery of this workload in a general practice setting.
At PBR rates of an average £250 per outpatient appointment this would mean a significant investment.
I would suggest that for every A and G sent back to practices, practices should receive a sum of money commensurate with the average number of outpatients saved in that speciality – so, a minimum of £250 for each one.
It also needs to be done in a managed way in order to build the capacity required in general practice.
None of this will be done, of course – they will try to get away with just dumping it on us, unfunded.

Guy Wilkinson 4 November, 2021 10:41 am

Ridiculous unfunded work dump.

Agree – a GP tariff for additional GP work arising from the AG would have to exist for this to work.

Dermot Ryan 4 November, 2021 10:50 am

This is a bureaucratic solution to a problem of scarce resources. Of course some referrals are inappropriate, in retrospect, but the majority are because there is diagnostic uncertainty or because the patient needs treatment.
NICE already ensures that most patients needing more expensive treatments can’t have them until they have wasted years of their life trying treatments which are ineffective or dangerous or both. The use of oral steroids in severe asthma comes to mind with increased levels of infection, obesity, diabetes, cataract
s, skin thinning, hypertension….etc when a biologic offers the opportunity for a return to normal or near normal life.
This initiative will be staffed by hordes of people who follow algorithms which need the needs of some 10% of the population. This is a massive over-simplification of what are always complex clinical issues but our managers have little understanding clinical medicine, only of how to count beans.
Will this be a final bullet that will end General Practice. Yes! if it is not vehemently resisted.

Iain Chalmers 4 November, 2021 11:58 am

Wholeheartedly agree Dermot.

I have contact to 4/22 and the growing selection of hair brained schemes thought up by chiefs to solve a problem because we have to few Indians is not doing it anymore for me.

Downside is I suspect will be consumer of this new type service & need to get flight to Dignitas arranged well in advance

terry sullivan 4 November, 2021 12:19 pm

all nhs gps should be employees–otherwise offer services privately–the demand is there imo as long as fees are fair

terry sullivan 4 November, 2021 12:20 pm

iain–all bureaucracies end up with too many chiefs and few indians

Chris GP 4 November, 2021 12:53 pm

An NHSE choice to transfer secondary care work to primary care is a choice to reduce patient GP access. At least 30 face to face a day, 60 prescriptions to review, 30 blood tests to review , 30 letters, a limitless number of tasks from admin staff, PCN meetings, appraisals, CQC…..I am doing all I can. You can bleat and moan – but I go home knowing I have done a fair days work. To ask anything more of me is unrealistic. Read my lips…..There is no more time in the day….There are no more GP’s. NHSE – This is your problem – not mine.

David Jarvis 4 November, 2021 12:59 pm

Of course if GP’s use this like patients use ask my GP I uspect the people offering the advice and guidance may struggle with the workload. I’m thinking the same amount of outpatients plus 65% advice and guidance.
The bureaucrats try to infantilise us without realising the consequences of us behaving back as they treat us.
The regulated have more time to circumvent the regulations than the regulators to invent them. For the most part when I refer it is because I have done what I can do and no advice is going to fix a cataract or a knackered hip or a bowel cancer. Or more importantly the imaging required to make a diagnosis and I suspect the lack of imaging is a big problem. Again due to lack of people as much as resources.

Doc Getmeout 4 November, 2021 2:43 pm

You can not be serious.

The GP will be treated like a SHO or junior by the consultant. Please do this and then do that and prescribe this, now refer somewhere else, and maybe weeks later, OK I could see ‘your’ patient.

More Hospital Dumping by the back door and glorified.

Patrufini Duffy 4 November, 2021 3:02 pm

You just refer it out of borough then. Hospital loses income and patient goes on a jolly.

Tim Atkinson 4 November, 2021 3:35 pm

If the local GPs are prepared to be dictated to like this then frankly they deserve what they get.

Slobber Dog 4 November, 2021 4:58 pm

Patient and patient groups need to be made fully aware by this CCG of the impact the scheme will have on their management.

Matt Hancock 4 November, 2021 5:23 pm

If they reject the referal redirect the patient to PALS, simple

Patrufini Duffy 5 November, 2021 5:38 pm

HERE IS THE WEBSITE FOR Royal Free + UCL – ***Private Patients. Plugged everywhere by email. The Consultants are busy, yes.

https://www.royalfreeprivatepatients.com/

https://www.uclhprivatehealthcare.co.uk/

And you can’t even sell a toothbrush on or sticky plaster. Hilarious NHS.

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