NHS England forced to address public concerns that GP referrals are being ‘rationed’
NHS England has been forced to defend its decision to mandate advice and guidance as part of GP contract changes coming into force later this week.
The Telegraph front page today warns that the NHS will ‘ration’ referrals in a bid to meet waiting list targets, and NHS England officials were also fielding questions from concerned members of the public at a board meeting last Thursday.
Pulse has reported extensively on the new mandate since the contract changes were announced last month, and NHS England primary care director Dr Amanda Doyle previously defended the move in an exclusive op-ed.
The £80m A&G enhanced service, which currently pays GPs £20 per episode of care will be absorbed into the core contract from Wednesday, with GPs now expected to use A&G in all cases where it is ‘clinically appropriate’.
Locally, ‘single point of access’ pathways will then be agreed – to come into force from 1 October – under which all referrals will be triaged by hospital consultants before they are accepted or rejected.
The recently-published neighbourhood health framework formally set a target for quarter of referrals to be ‘diverted’ in this manner for 10 high-volume specialties by next March.
At NHS England’s board meeting last week, Dr Doyle was asked was questioned by the public on how contractual changes interact with doctors’ ‘professional duty’ to refer patients to specialist care ‘where this is in the patient’s best interests’.
In response, Dr Doyle said the changes would lead to ‘faster consultant-led decisions and clearer next steps’ while maintaining GPs’ right to refer.
She said: ‘GPs’ clinical decision to refer is unchanged in the new contract. Nothing in the new contract changes their responsibility to act in their patient’s best interest. There are no new contractual barriers to referral. GPs can refer exactly as they always have, and claims about new hurdles aren’t correct.
‘The changes actually relate to secondary care and the way in which referrals are triaged, not to GP obligations to act. Expanding advice and guidance simply means that patients will get faster consultant-led decisions and clearer next steps, rather than putting any sort of barrier into the process by which they get referred.’
Dr Doyle also said there was ‘no conflict between what’s in the contract and the professional duty of GPs’.
Meanwhile, in response to the Telegraph article, an NHS England spokesperson said A&G ‘has a major role to play in the coming years to support clinical decision-making and ensure patients are directed to the right specialist care as soon as possible’.
‘While the NHS delivered record numbers of appointments in 2025 and reduced the waiting list to its lowest level in three years, we have much further to go to ensure planned care is easier to access for patients,’ they added.
However, the assurances come as NHS England previously told Pulse that not even Jess’s Rule – where clinicians are urged to take a three-strikes and refer approach – will mean consultants have to accept a GP referral.
The BMA last week urged the Government to ‘pause’ its plans for mandated A&G, and to put in safeguards in relation to same-day access. If it does not, the BMA said it could launch collective action from 30 April.
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READERS' COMMENTS [8]
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NHS England, DHSC and successive governments have progressively been creating, ever increasingly more complex and ‘hidden’ patient ‘fobbing off ‘ systems to the detriment of patients and staff but to the benefit of themselves and their misleading NHS performance figures or political ambitions.. The RCGP in particular imo has singularly failed over decades to relay this subterfuge to the those that can apply the most pressure i.e. patients and the public and
effectively allowed this to occur in my view with no effective challenge.
Exactly CC. So many examples of waiting list massaging and referral obstruction that are not in the public conciousness. Like MSK spinal referrals for radicular symptoms only becoming live after MRI demonstrating impingement completed with waiting list of many months for said MRI; trusts financially incentivised to reduce waiting lists which they do by sending txt/letter to patient, often ignoring responses and removing patients from lists to have to then recommence the referral process; attrition to waiting lists with patients spending their hard earned savings to seek interventions outside of NHS in desperation; waiting lists published ‘for clinicians eyes only’ demonstrating extraordinary waiting times most more than 12 months to OP appointment for most. And all the while NHSE and HMG trumpeting nonsense as above
This story has taken far too long to make the nationals. This has been going on for years. What is the BMA doing?
The changes outlined by NHS England are a clear attempt to undermine the autonomy of GPs under the guise of streamlining care and addressing waiting list pressures. While the statement that GPs retain the right to refer is technically true, the reality of the new A&G and triage system means that many referrals will be delayed, diverted, or outright rejected based on financial and operational targets rather than clinical need. This represents a systemic shift away from patient-centred care and towards a rationing approach driven by cost containment.
For GPs, this is more than just an administrative burden as it erodes the core of our professional duty to act in the best interests of our patients. The notion that A&G will “speed up” care and provide clearer next steps is a false promise when the actual effect will be increased delays and increased pressure on GPs to make decisions based on bureaucratic processes rather than clinical judgment.
However, there’s a potential opportunity here for GPs to regain some control by exploring a new model, one where GPs contract secondary care services externally, seeking investigations and specialist assessments outside of the NHS framework. This model could allow GPs to choose the most economically advantageous management options for patients, while reserving NHS resources for the most critical and dramatic situations. This shift could lead to a more efficient use of resources and potentially restore some autonomy to the profession.
But, is this the scenario we truly want to see? Are we comfortable with a system where the NHS is relegated to handling only the most dramatic cases, and GPs are left to manage the rest within a contracted framework? This raises fundamental questions about the future of healthcare delivery and whether we are willing to fragment care in this way, leaving behind the NHS’s founding principles of universal access and comprehensive care.
It’s time for us to push back against these policies and protect the role of the GP in advocating for the best possible outcomes for patients.
“GPs’ clinical decision to refer is unchanged in the new contract.”
A clear deception to change the meaning of ‘refer’. I think BMA should test this is court by judicial review.
This fundamentally changes patients’ right to see a specialist. GPs no longer have the agency to contract for an appointment. The meaning of ‘refer’ has long historical precedent and is entirely distinct from ‘seek advice from’. Patients will not receive the same service from GPs, GPs do indeed lose their right to refer, with the many risks already attested to.
Doyle doubling down with Orwellian levels of deception. The implications are sinister.
Optimistic to expect the BMA to do anything useful here; the activists are too busy “saving the NHS” and preventing Palantir from doing anything to improve NHS IT to have concerns about patient outcomes
The advert above was brought to you by Haddock Inc…..What’s Palantir got on you, Dave? 😉
Plan B in any form is acceptable to me now, BMA