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NHSE: GP ‘advice and guidance’ requests avoided over one million ‘unnecessary’ referrals

NHSE: GP ‘advice and guidance’ requests avoided over one million ‘unnecessary’ referrals

GP ‘advice and guidance’ (A&G) requests ‘almost doubled’ in 2020/21, avoiding one million ‘unnecessary’ hospital attendances, NHS England has claimed.

According to NHS England’s annual report and accounts for the financial year, A&G requests reached over one and a half million requests – two-thirds of which did not result in referrals.

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

And the Government’s long-awaited elective recovery plan – published yesterday – stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G.

PCNs are due to be incentivised for using A&G through ‘Investment and Impact Fund’ (IIF) points worth £9.9m in 2022/23, however GP leaders have raised concerns about its workload impact in general practice.

Meanwhile, NHS England has set a national target requiring GPs to use A&G for 12 out of 100 outpatient attendances by March this year.

NHS England’s 2020/21 annual report said: ‘During 2020/21, GP usage of A&G almost doubled, with the total number of A&G requests via the electronic referral system alone exceeding one million. 

‘Including all other platforms, [the] number of requests are estimated to be 1.58 million for 2020/21, leading to around 1,040,000 unnecessary face-to-face outpatient attendances being avoided.’

The report added that A&G ‘supports primary care clinicians to access specialist secondary care advice without the need for referral’, with advice ‘often’ provided within 48 hours of the request.

A&G ‘avoids the need’ for a GP referral to secondary care ‘in most cases’, it said.

By March 2023, NHS England has said that integrated care systems (ICSs) must deliver ‘16 specialist advice requests, including advice and guidance (A&G), per 100 outpatient first attendances’ but it remains unclear how many should be GP A&G requests.

However, for England’s GPs, the focus on A&G raises workload concerns.

Tower Hamlets LMC chair Dr Jackie Applebee told Pulse: ‘They always look at it from the point of view of the hospital. It might have meant that there were a million fewer referrals into hospital, but what they don’t ever think of is the impact on general practice and how much extra work it was for us. 

‘As long as it stops the referrals into the big shiny building – that’s all they seem to really care about.’

It’s ‘really hard to quantify’ workload in general practice, unlike in hospitals where there are ‘hard statistics’ such as four-hour waits and waiting lists, Dr Applebee added.

She said: ‘All we know is that we’re horribly busy. In theory, it’s great. If a patient doesn’t have to go to hospital, that’s better for the patient as well. 

‘[But] my question would be – have they looked to see what the workload was for general practice? And have the resources been shifted out to general practice to cope with that?’

Professor Azeem Majeed, GP and professor of primary care at Imperial College London, told Pulse that A&G has ‘mixed benefits’ but creates extra workload for GPs that must be resourced.

He said: ‘[A&G] has been useful for many patients as GPs can often get a reply from a specialist quicker than from a conventional outpatient appointment.

‘But it has also meant that sometimes extra work is pushed into primary care  – for example, requests for investigations, initiation and titrating of medication – without any extra funding.’

He added: ‘Going forwards, it’s essential that the NHS GP (GMS) contract recognises this so that any extra work for primary care teams created by A&G is adequately funded.’

A&G: Workload and resourcing concerns

Pulse revealed in November that an LMC has called for GP practices to be paid £12.50 per A&G episode to resource the extra workload.

It followed a major London trial assessing advice and guidance as the single point of access for referrals and a CCG target to cut GP referrals by 65% through A&G.

Meanwhile, GP leaders demanded an end to hospitals being allowed to mandate the use of A&G before accepting GP referrals of patients to secondary care at the LMCs Conference in November.

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

They have also previously raised concerns that advice and guidance is yet another form of ‘workload dumping’ from secondary care and cautioned that patient referrals may be declined in error.

Research carried out on behalf of NHS England in 2020 concluded that A&G represents a ‘significant time and resource challenge to primary care’ and that general practice staff ‘do not have additional time to follow up A&G actions’.



Please note, only GPs are permitted to add comments to articles

Dermot Ryan 9 February, 2022 11:04 am

Typical NHSE spin: all it did was add to the complexity of getting assistance for the patient. They measure transactions as a prevention. They do not provide any degreeee of certainty or relaibility , nor do they lead to better outcomes for patients. They are in fact a costly unnecessary step in providing patient care with no added value.
Do not believe anything NHSE says or claims.

David jenkins 9 February, 2022 12:11 pm

“NHSE said”…………….so obviously it must be true !!

i very much doubt it “avoided” these referrals – more than likely it delayed the inevitable. in the meantime, any pathology that actually IS there will probably be “cooking” for longer. no doubt this will increase morbidity, and possibly mortality. and it will obviously be “the GP’s fault” the patient wasn’t referred sooner.

i urge everyone who is affected by this drivel to document in fine detail any delay in accepting referrals, so that when the shit hits the fan any adverse outcome was not down to us.

the bottom line is, as always, “i have seen the patient and you have not, and i think referral is necessary”.

Simon Gilbert 9 February, 2022 1:00 pm

Were these GP initiated A@G referrals? If so these are a completely different cohort of patients/queries than patients who GPs have chosen to make a traditional referral for, and one can’t extrapolate the results to apply them to a wider cohort.

Darren Tymens 9 February, 2022 1:01 pm

Alternative headline: ‘failing hospitals shift 1 million extra unfunded appointments (and associated significant clinical risk) onto practices’

Not on your nelly 9 February, 2022 2:30 pm

I actually quite like the A&G system if used correctly. I use it to ask clinical question/advice regarding a test result and whether it requires a referral.

I usually get a rapid response and roughly half of mine end up not needing a referral. If one is needed most of the time the consultant responding arranges the referral. I do agree however, that it can increase workload and so this should be properly funded. 9.9 million across England is an absolute pittance. I’d love to know how much hospitals get to give an A&G response…!

Patrufini Duffy 9 February, 2022 2:45 pm

You save a referral at your own crucification. Be careful which one you fob off for that bar chart of yours. No NHS manager is going to come and say thank you.

Patrufini Duffy 9 February, 2022 3:04 pm

Here’s a study for the Professors.
What % of GP referrals are done because the member of public is purely annoying, demanding and incapable of taking GP advice. Make it happen. Might become Emeritus with that one. Remember, public, not patients.

Bonglim Bong 9 February, 2022 3:56 pm

That sounds great.
1 million appointments saved is £200MILLION pounds saved.
And how much of that is being reinvested in to General Practice to make up for the extra secondly care worked dumped on to primary care? The whole 200M? 150? even half at 100M?

No….. 10M…… and only if you push up A+G even further.
Slow handclap for NHS England.

Rogue 1 9 February, 2022 4:35 pm

I think you’ll find it is actually 1 million UK patients have been denied access to their consultant in the last year. On the pretext of advise, even though we only refer when the case is too complex to be managed in primary care and needs a consultant investigation and input! Another great failure wrapped up and spun at a positive?

Turn out The Lights 9 February, 2022 4:47 pm

More NHSE hyperbole from the BS Boris school,the turd has been well and truly glittered.It still a brown and smelly way of trying to spread the jam even thinner.It stil stinks and pushes a awful lot of clinical risk our way as we are the ones who have usually seen the punter.Next step will be A&G from a consultant based halfway across the world where they will cost less or even from an App they seem ever so fond of.End of days my friends

David Church 9 February, 2022 5:54 pm

Once upon a time, you could either refer a patient to hospital clinic, or you could phone up you Consultant colleague for advice.
But now you have to make an ‘Advice and Guidance’ referral instead, so that NHSE can say how many could have been satisfied less bureaucratically in the old system!

Patrufini Duffy 9 February, 2022 7:06 pm

Pointless data. Advice doesn’t mean you were going to refer. Some just want some company and chit chat with a colleague, outside of the grey GP walls.

Claire Mutch 10 February, 2022 12:13 pm

I’ve had to do 4 A&G for the same patient to get them an appointment. Reply’s include asking for information I’d already included, repeating tests already back in case they changed. “GP to consider starting……” medications I’d tried and had mentioned they hadn’t worked in the letter. BUT three referals avoided so hurrah for A&G.

James Weems 13 February, 2022 8:18 pm

This is unfunded GP Work. End of.