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Revealed: NHS England’s plans to replace traditional GP referrals

Revealed: NHS England’s plans to replace traditional GP referrals

Exclusive An NHS England document has confirmed that that it wants to ‘optimise’ GP referrals to secondary care via an enhanced model of advice and guidance.

GP leaders recently raised concerns that NHS England had encouraged ICBs to adopt the ‘advice and refer’ model, effectively replacing traditional GP referrals and adding barriers for patients in accessing secondary care. 

At the time, NHS England did not address concerns about this specific model, but Pulse has now seen a ‘framework’ document which encouraged local commissioners to ‘strengthen’ specialist advice services in order to ‘optimise’ referrals. 

The guidance suggested the use of the ‘advice and refer’ model, which means all referrals or advice requests from GPs ‘come in through one route’ and directly bookable appointments are ‘discouraged or removed’.

Under this service, all referrals are then ‘triaged’, allowing hospitals to reject referrals and send them back to GPs with advice. 

This mechanism removes the option for GPs to send standard referrals, whereas the usual model of advice and guidance (A&G) allows GPs to seek advice if they wish, but maintains the direct referral route.

NHS England emphasised its commitment to empowering regions to ‘develop diverse models’ of specialist advice in line with their local needs.

The document, shared with commissioners in March on an NHS platform not available to the general public, is intended as a ‘generic blue-print for local development’ of each area’s own commissioning model for ‘referral optimisation’. 

But while there is no national directive, ICBs were advised to implement a ‘system wide’ approach to commissioning A&G models.

The guidance said: ‘Referral optimisation across primary and secondary care can be improved by Specialist Advice services designed to enhance efficiency and quality in referral management.

‘These services can improve collaboration and communication between clinicians.  They can support better patient self-management and ensure that patients are seen more quickly by the right professional and in the right setting.’

NHS England specification for ‘specialist advice’ models

Advice and Guidance

  • The referring clinician can seek advice and guidance from a specialist supported by asynchronous and synchronous communication methods before referral.

Advice and Refer

  • All routine referrals / advice requests come in through one route, with directly bookable options discouraged / removed. All referrals / advice requests are then triaged, this allows secondary care to triage and assess the referral before either:
    • Offering advice
    • Requesting further information – opening a dialogue to discuss management.
    • Accepting as a referral.
    • Accepting the referral and recommending interim management before the initial appointment.
  • Pre-hospital referral triage, referral management centre, single point of access supported by artificial intelligence (AI) tools.

The GP Committee England warned last month that ‘mixing up A&G and referral will lead to medicolegal jeopardy’ as well as increased risk of patient harm.

In response to these concerns, NHS England argued that advice and guidance ‘improves the referral process’ for some patients, while for others it ‘avoids the need to wait for unnecessary outpatient appointments’.

NHSE also emphasised that local systems ‘have the freedom to adapt the specialist advice’ to best suit patient needs.

In recent guidance, the GPCE urged GPs to ‘cease taking part in A&G from 1 June 2024’, unless pathways have been agreed by LMCs and there is ‘appropriate funding’.

The union clarified that this is a recommendation for now, but GP practices may be directed to stop engaging with advice and guidance pathways as part of collective action, pending results of the ongoing ballot.

GPCE clinical and interface policy lead Dr Clare Bannon wrote: ‘Recently Acute Trusts and ICBs (Integrated Care Boards) have started to mandate that in some specialities all referrals must go via A&G, sometimes badged as “intelligent triage”. 

‘This can create further workload for GPs in arranging additional investigations or follow up appointments.’

She highlighted that A&G ‘cannot be mandated instead of a referral’, as per the NHS Standard contract. 

According to a survey conducted by NHSE last summer, 23% of PCNs reported use of ‘advice and refer’ models, while a quarter said they had local enhanced service agreements in place for A&G pathways.

One of NHS England’s priorities for this financial year is for local commissioners to expand advice and guidance to ‘avoid unnecessary referrals’, according to planning guidance published in March.

And last year, the national commissioner pushed the use of a triage system for the musculoskeletal (MSK) pathway – known as ‘referral assessment services’ (RAS) – which explicitly allows rejection of GP referrals.

Despite these recommendations to ICBs, NHSE leaders have previously told Pulse that there will be no national mandate for GPs to use advice and guidance in a certain number of cases.



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

Andrew Jackson 26 June, 2024 5:48 pm

If I refer say 1 in 10 currently to an OPD appt and they now are managed by A+G then I need another appointment to put in place the plan i.e you have immediately removed 10% of my forward capacity plus the additional FU I will need to do to make sure the A+G was successful.
I have no problems doing this (it will be back to the days of enjoying complex management) but the punters have to accept that the price to pay for not travelling to the hospital is a huge reduction in access to general practice appointments.
Is this a trade off that is acceptable as there isn’t enough workforce currently to do both?

Michael Green 26 June, 2024 6:18 pm

National Crap Service. What a dump this country is becoming.

Christopher Castle 26 June, 2024 7:18 pm

Hospital Specialists triaging referals from an extended workforce. This explains why the workforce plan has no need for GPs. They are removing triage from General Practice and placing it in the hands of hospital specialists. Ofcourse this completely misses all of the complex conditions managed by GPs without referal and beyond the competency of the extended workforce. There is also the delusion around efficiency of this model dreamt up by management consultants that don’t understand and implemented by inexperienced NHS executives that don’t have the morals to question. Too bad we will see declining health outcomes. Will an election stop this?

David Church 26 June, 2024 10:25 pm

We were always able to have referrals direct to Consultant responded to by a letter back from Consutlant with advice – the only difference was that it was your local consultant, and there were learning opportunities, not some distant consultant who does not understand local access issues and the strengths and weaknesses of their own local GPs to manage the patients.

Mark Howson 26 June, 2024 10:39 pm

I used to work in ENT as clinical fellow and I would say more than 60% of what I saw could be perfectly well managed by their own GP. GPs do have areas missing from their experience and each GP has different experiences. A&G is a good way to explain what is perfectly treatable in GP and improve the general experience and knowledge of the GP body leading to a better experience for patients all round. As explained above this doesn’t mean it is cheaper. And the “savings” made in 2ndary care by this more efficient and effective system would need to be transferred to GP. Hopefully with a new government funding will rise for the NHS and a larger %age of that pie needs to come to GP for it to be more effective.

Yes Man 27 June, 2024 8:21 am

@Mark Howson you are absolutely right. There is a massive number of unnecessary referrals to secondary care but there are reasons. One reason is the countless unsupported non-GPs and trainees. Another reason is even fully qualified GPs need a few years to reach a good standard of practice ie GP training needs to be at least 5 to 7 years long.The government decided that it’s too expensive to fix the issue hence the current situation. They are wrong as they have been with everything else and I can’t wait to see the back of them.

Jude the Obscure 27 June, 2024 8:34 am

With secondary care taking 93% of the NHS budget its no surprise that every initiative is about making life easier for secondary care. Everything is viewed through the eyes of someone working in a hospital. Because thats where all the money is. Of cause hospital Drs receive referrals that they don’t like. GPs get a whole heap of utter crap from Hospitals too but thats barely mentioned. Every single day I work I read letters from clinics and 111 with almost nothing in them. Utter dross. Yesterday a urologist who didn’t even bother to write a single word! All there was, was a list of jargon diagnosis and a plan involving PSA bloods every three months and an MRI in 6. Absolutely no mention of who is going to do the bloods (this idiot no doubt simply assumed we would) and guess what no MRI 9 months later.. just a furious patient who wanted to ring my neck out of anger at a urologist they’d apparently never seen who couldnt be arsed to even write a sentence . The answer is not to scrap correspondence from hospitals any more than it should be scrapping referral letters from GPs. Its like they held a meeting with two people to decide what to do about the NHS. One guy is 9 times bigger and louder than the other (in line with funding) ..each sees approx 50% of all the patients. The ONLY one being listened to is the over fed oaf aka the Hospital. Stop putting ALL the focus on what GPs need to do better!! We only get 7% of all the feckin funding OF COURSE WE ARE STRUGGLING! Lets talk about HOSPITALS..that is where all the money is getting spent FFS. Are we all blind?? You people out there making strategic decisions about the are a bunch of MORONS

Peter Jones 27 June, 2024 9:24 am

A and G is useful – but ONLY if it is voluntary on the part of GPs – who are the ONLY ones who know when it is appropriate.

Jock Tamson 27 June, 2024 10:12 am

Past experience of “total triage” (for orthopaedics) in our neck of the woods suggests it is counterproductive. Rather than manage patients in primary care and only refer when clinically indicated, it creates an incentive indeed an imperative to refer early, rapidly swamping the triage service. The law of unintended consequences rules!

Bonglim Bong 27 June, 2024 10:53 am

The ultimate problem is asking GPs to do tasks beyond their competence – and the pressure on consultants to keep appointments low means it is routine:
– Please see this patient with hypertension – he is on amlodipine. Declined, why don’t you try ramipril/ losartan, then indpamide? – that is fine, it includes steps which GPs can and should be able to manage.

– Please see this patient with an abnormal echocardiogram suggesting cardiomyopathy.
–> Please request a cardiac MRI, you can add my name to the referral and they will do it. Once you have the result re-refer; is totally inappropriate because GPs are not able to interpret or manage the results of the cardiac MRI.

And please repair this chaps hernia, he has angina.
declined, please re-refer after a cardiology referral/ review to make sure they are fit for an anaesthetic/ the procedure. Again not appropriate as the anaesthetist needs to make that decision, not.a GP.

So the bird flew away 27 June, 2024 12:58 pm

This NHSE mechanism does not serve patient care interests. It pushes more of the secondary care side of the costs of the spectrum of managing uncertainty backwards onto GPs (who are cheaper than secondary care and so they’re burdened even more from both ends, the patient and then hospital).

The real underlying reason for this mechanism is to turn the why and what we GPs do into data and process, so it can be algorithmised – which will shorten the journey to when GPs have to submit to corporate AI’s interrogation before they can refer. The NHS, primary care, patients and GPs complex decision making are the guinea pigs in this brave new AI world.

Centreground Centreground 27 June, 2024 1:37 pm

Until these unnamed NHS England managers face the same penalties as doctors when putting patients (& healthcare professionals) unnecessarily at risk by their bizarre detached policy change, pilot and experimentation addictions , this rampant tinkering and destruction of the NHS and increasing risk will persist.

Rogue 1 27 June, 2024 4:50 pm

Perhaps we should just start sending all out referrals to out local MP, and let them sort out this fiasco!
It is nothing more than a way of not seeing patients, and massaging waiting list figures – call it out for what it is

Truth Finder 28 June, 2024 3:54 pm

Imagine you are the patient. Is it a good service? No. Being treated like numbers and dirt. Concerns does not matter. They get screened without without even talking to the patient.