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RCGP has asked NHS England not to mandate advice and guidance

RCGP has asked NHS England not to mandate advice and guidance

The RCGP has ‘voiced concerns’ with NHS England about any proposal to mandate that GPs use advice and guidance (A&G) in all cases instead of direct referrals. 

The college said it is among a number of stakeholders NHS England has involved in advising on a new outpatient strategy, which is under development.

While in some areas the A&G has been a ‘helpful tool’, in others it seems to be a ‘barrier to artificially protect waiting lists’, RCGP has told NHS England.

Yesterday, it was reported that NHSE is working on a national outpatient strategy, due by December, which would aim to increase the use of A&G pathways. 

The Royal College of Physicians (RCP) is working with the national commissioner on this strategy, and their outpatients lead Dr Theresa Barnes has said there should be a ‘push’ to use A&G ‘in preference to direct referrals’. 

To develop these plans, NHS England has held four stakeholder events which included primary care representation, but Pulse understands that no decisions have yet been made.

The RCGP has told Pulse that during ‘ongoing discussions’ with NHSE on the strategy, they have raised concerns about GPs being obliged to use A&G for all referrals.

Chair Professor Kamila Hawthorne said: ‘We’ve seen disparities by region, with some of our GPs saying that, when resourced appropriately and implemented well, it is a helpful tool to increase communications with their colleagues in the rest of the system. 

‘In others it seems to be used as a barrier to artificially protect waiting lists and prevent patients getting the care they need. 

‘This can have significant impact on already overworked GPs dealing with the spillover of a greater number of referrals that are delayed or rejected.’

She added: ‘We fully support a closer relationship between primary and secondary care, along with any measures to ensure a smoother referral process for patients. 

‘However, A&G should only be used to do what its name suggests – provide advice and guidance rather than act as a barrier to timely patient referrals.’

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

A&G has been used since 2015, however NHS England formalised the pathway in 2021 when it introduced a target stipulating that GPs use it for 12 out of 100 outpatient attendances.

In January 2022, as part of plans to tackle the elective backlog, NHS England increased this target to 16 specialist advice requests, including via A&G, per 100 outpatient first attendances

However, in November, a National Audit Office report showed that GPs were already managing 22 patients out of every 100 they referred via A&G from April to June 2022

Chair of the BMA’s GPC England Dr Katie Bramall-Stainer said expanding A&G is ‘not a viable solution’ given the ‘current constraints of an overstretched and under resourced system’.

She said: ‘GPs appreciate every day the impact of millions of their patients waiting for specialist treatment – keeping those patients safe as their symptoms progress is in turn putting surgeries under significant pressure.’

‘Greater investment in general practice with a focus on retaining the GPs we have and recruiting more back into the profession is ultimately what is needed to make headway into managing the growing unsustainable pressures that the NHS is facing,’ Dr Bramall-Stainer added.

Earlier this year, a think tank report warned that mandatory A&G pathways could be storing up a ‘hidden backlog’ of patients ‘by allowing treatable conditions to deteriorate’. 



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

Dunit GottheTshirt 21 September, 2023 5:59 pm

RCGP “raising concerns” is a completely inadequate response. Mandating A&G for all referrals will completely undermine General Practice.

Centreground Centreground 21 September, 2023 6:19 pm

In my view, in this scenario we have a totally hopeless and ineffective organisation such as the RCGP interacting with a completely inept organisation with one of the worlds longest and most disastrous track records of failure i.e. NHS England – it could only be worse if a PCN Clinical Director entered the fray.
It may be advisable to leave this to the BMA which has at least developed some teeth and is having some impact in a number of areas against the wider UK media onslaught

Nick Mann 21 September, 2023 7:23 pm

Until RTT times are ‘back to normal’ it’s unsafe to expand A&G.

There is no proper evidence at all that GP referral levels are too high, despite a decade spending hours each month in general practice auditing every referral. We’ve had Optum’s (UnitedHealth) and others’ Referrals Management Programmes/Teams inappropriately bouncing referrals back to GPs for years.

Advice is always useful if timely. Proper workup of patients prior to referral should be standard. But:

I don’t think mandating A&G before referral is safe for patients.
I don’t think A&G will make any dent whatsoever in the 7.7m waiting list.
It will create wider holes in the safety net.
It will piss off patients delayed unnecessarily, who will blame (often aggressively or in litigation) the GP.
It will piss off GPs who 98% of the time, know exactly which patients need referral.

So what is ‘No referrals A&G’ designed to achieve, precisely?

Andrew Schapira 21 September, 2023 7:40 pm

My experience
It can be useful if used appropriately
However I wonder if the reasons for introduction are political to massage waiting lists
I have not seen outcomes from pilot studies
I wonder whether there is is a transfer of risk and if this has been fully considered
I do not know whether the costs to primary care have been fully considered
I don’t know whether the ers system adequately informs the referer of the outcome

Imogen Bloor 21 September, 2023 9:09 pm

‘ I wonder if the reasons for introduction are political to massage waiting lists’ Andrew Schapira – I do too – is this just strategic deferral of referral, in turn creating the issues Nick Mann outlines?

Andrew Jackson 22 September, 2023 8:18 am

We have IT integrated A and G locally and it has a useful but very limited role. It can work well in specialties where decisions are based frequently on indices in blood tests eg haematology, renal, liver or opinions on scan results but is hopeless for specialties where the patient needs an examination, surgical opinion, has pain or other softer symptoms.
Our team probably use it about 1 in 20 referrals.
There are issues with knowing when the reply wil come back and it always leads to more work, at a minimum another consult with the patient and often more work up.
I recently had an osteoporosis referral to access IV or injectable treatment (which we do via A and G. The first recommended an OPD referral (why it couldn’t be just converted I have no idea), then the patient got an appointment which was then cancelled and I was asked to submit a second A and G instead after performing x-rays. The hassle, work and patient communication took ages compared to doing a referral for something I can’t do in primary care.
If it is mandated for all referrals we will sink further under more unfunded work.

Truth Finder 22 September, 2023 2:12 pm

It just shows how clueless NHSE is.

Richard Greenway 22 September, 2023 3:32 pm

This won’t help retention in General Practice which should be a key focus.
GPs have been gatekeepers, and kept referrals to manageable levels historically -and this function needs to be valued and nurtured with more staff and pay.
Putting a barrier like A&G just duplicates work for GPs and ties up consultants who need to be seeing patients. Too many times we get and A&G that takes weeks and just says “please refer” anyway -more paperwork (should be atomatically converted) , and delay. Rejections when they come are rarely justified, and also create work.

John Graham Munro 23 September, 2023 9:11 am

Do we have ”domiciliary visits” anymore?———–just like the old days

Long Gone 23 September, 2023 9:13 am

Very reassuring that the RCGP have rejected this proposal so “strenuously”.
No doubt the BMA response will be slightly more robust.
But it will probably imposed regardless.

George Forrest 23 September, 2023 5:57 pm

I use A+G when I DON’T want to refer – when all I need is some specific information or help to choose the best of several management options so I can continue to look after the patient myself.
Funnily enough, I refer when the patient needs stuff I can’t do or provide; which, of course, is bloody obvious 99% of the time because I’m a trained, qualified, and experienced GP.
Mandadating A+G for every referral is illogical, inefficient, and insulting. It would be the ultimate Secondary Care dump. Offloading an enormous chunk of Hospital workload on our side of the interface, for us to do for free in extra hours added on to our current working day presumably?!