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.
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.
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.
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’.