Mandating GPs to use advice and guidance (A&G) pathways instead of referring patients could be storing up a ‘hidden backlog’, experts have warned.
While a ‘fall in GP referrals may on the surface appear to be a positive contribution to [NHS] productivity’, it could be creating a backlog of patients ‘by allowing treatable conditions to deteriorate’, leading to ‘more unplanned admissions’ to hospital later down the line.
The warning was made in a report written jointly by the Institute for Government (IfG) and Public First, and funded by the Health Foundation, which assessed why NHS hospitals are failing to deliver higher activity despite higher spending on the service and higher levels of staffing over the last couple of years.
The IfG report also said that the plan for GPs to use more A&G in order to tackle elective backlogs had shown ‘limited evidence of effectiveness so far’. While there has been an ‘overall drop in the percentage of GP referrals leading to appointments since the pandemic’, research is ‘urgently needed’ into the impact on patient outcomes, it said.
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.
The authors said: ‘It is possible that expanding A&G further could help reduce the backlog and the pressure on hospitals but it is also possible that this combined with rejected or failed referrals is storing up bigger problems for the future.
‘And that a lack of transparency may be hiding the true scale of the challenges faced by the NHS.’
The NHS does not currently publish data on the characteristics or outcomes for patients who have been treated as A&G requests which means there is little evidence of the overall impact of this pathway, according to the report.
It also argued that although Covid was the ‘trigger’ for the NHS crisis, the ‘bullet had already been loaded beforehand’ since productivity had been decreasing in the years prior.
Pointing to workforce and activity data, the authors showed that while, for example, the number of FTE junior doctors increased by 16.4% between 2019 and 2022, the number of outpatient appointments is down by 2.6%.
However, the data showed an inverse effect in primary care, where the number of fully qualified GPs has reduced over the same period, while the number of GP appointments has gone up.
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.
Professor Azeem Majeed, professor of primary care and public health at Imperial College London, said: ‘In most areas of the NHS – with the exception of general practice and urgent cancer referrals – productivity is lower now than a few years ago.’
He added: ‘For GPs, the perception is that A&G has led to increased workload as many patients who previously may have been managed in an outpatient clinic are now managed in primary care.
‘Many patients also don’t like A&G as they assumed they were going to be seen by a specialist. However, robust data on A&G is still lacking.’
Professor Majeed did not think A&G has had a ‘major impact on patients deteriorating’, and ‘long waiting times for specialist investigations and treatment’ would have a ‘bigger impact’ on patients’ clinical condition.
Earlier this year, a Pulse survey revealed that two-thirds of GPs feel A&G is preventing patients who really need a referral to secondary care from getting one.
And in February, GPs in Lincolnshire raised concerns about a new A&G colorectal cancer pathway, saying it increased patient risk and also workload for GP practices.