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NHS England looking to ‘replace’ direct GP referrals with A&G, GP leaders fear

NHS England looking to ‘replace’ direct GP referrals with A&G, GP leaders fear

Exclusive GP leaders fear that NHS England plans to replace the traditional system of direct GP referrals, with ICBs now being encouraged to take up an enhanced form of A&G.

In pilots that have taken place in Tower Hamlets, GPs send their query to the hospital department and the hospital decides whether to accept it as a referral or issue advice about managing the patient in general practice.

According to the BMA, NHS England is hoping to roll this system out on a national level but the GP Committee for England said this risked adding barriers for patients to access secondary care.

A BMA message to LMCs said that NHS England was ‘attempting to merge’ A&G with referrals into a new ‘advice and refer’ model.

The BMA asked GPs to share feedback with NHS England about their experiences with A&G, warning that that ‘mixing up’ A&G and referral could lead to ‘medicolegal jeopardy’.

The message, shared by Kent LMC, said: ‘Think about what you as a GP want and what your patients need.’

‘For example, mixing up A&G and referral will lead to medicolegal jeopardy, increased potential for patient harm, falling through the cracks.

‘Where GPs do find A&G useful they will use it and where they don’t, they won’t – and forcing this will not work.

‘The direction of travel appears to encourage trusts to offer a format of A&G rather than referrals. So any case examples of this are extremely important.’

GPC chair Dr Katie Bramall-Stainer told Pulse that placing ‘extra barriers’ between patients and specialist care will confuse patients and put more pressure on practices.

She said: ‘Patient referral is a complex process, and the current demands of the advice and guidance system are already impacting workloads with the requirement of further investigations, treatments and information.

‘Placing extra barriers between patients and specialist care will only confuse patients and heap more pressure onto general practice.

‘We would remind GPs that this is not contractual, and GPs do not need to comply with this pathway, unless it has been locally commissioned and resourced, or it removes needless bureaucracy.’

She added: ‘If NHS England want to enhance access, the only plausible solution is to provide the NHS with adequate funding into the workforce, rather than attempting new, untried initiatives.

‘Only then will patients be able to receive the safe and effective care that they deserve in good time.’

NHS England refused to give details on the new plans, but said that they will not mean all potential referrals have to go through advice first.

However, it added that local systems ‘have the freedom’ to adapt the specialist advice model to ‘better suit’ the needs of their patients.

An NHS England spokesperson said: ‘Advice and guidance is offering tens of thousands of patients a way of accessing the advice of specialists quickly, and for some patients this will avoid the need to wait for unnecessary outpatient appointments, while for others it can help improve their referral process and lead to quicker diagnosis and treatment.

‘Local systems have the freedom to adapt the specialist advice model to better suit the needs of their patients and continue to be supported to monitor the benefits and understand any variation.’

Lincolnshire LMC medical director Dr Reid Baker said that A&G does bring ‘potential risks’ to the patient and increased workload and expectation of general practice.

He told Pulse: ‘Locally, there can be challenges with having A&G requests converted to OPA for patients, which is something that needs further work.

‘To add in referrals to this somewhat confused system will likely exacerbate these challenges and risks delays, referrals not being picked up and potentially patient harm.

‘There are concerns amongst colleagues of the potential medicolegal risks if harm does come to a patient through such changes. 

‘Ultimately, GPs have the right to refer clinically appropriate patients for specialist review. We do not need to use hospital designed proforma or complex referral mechanisms so if we have concerns about any risk to patients of system changes, we should be clear that we will not use such systems.’

Tower Hamlets GP partner Dr Selvaseelan Selvarajah told Pulse that practices in his area receive funding to process the ‘advice’ side of ‘advice or refer’ and said that GP representatives need to be involved in designing the new plans.  

He said: ‘In Tower Hamlets we are paid to process the advice part of “advice or refer” as it has been recognised by all this is work transfer to general practice.

‘The way it should work is: GPs send the query to the hospital department and if the hospital team accept it as a referral then that is fine.

‘If they respond with advice about managing in GP, then this activity needs to be funded.

‘We also need to have local and national GP reps involved in the design of these pathways as various levels from ICB to NHSE.

‘The design also requires local agreement about which specialities lend themselves to Advice or Referral, appropriate response times and joint regular updates.’

In November, NHS England told Pulse there will be no national mandate for GPs to use advice and guidance in a certain number of cases.

Pulse’s recent analysis of how A&G is being used across the country found that GPs are concerned about the increased workload it brings, the medicolegal implications, and the lack of resourcing in primary care.  



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

Mark Howson 15 May, 2024 12:59 pm

I think A&G has its place. It is more efficient than trying to phone the other doctor for advice and there is a record.. However NHSE interfering with how doctors refer to each other is a matter for the colleges and GMC. would perhaps comment on.

Simon Gilbert 15 May, 2024 1:01 pm

Medical Generalism without the ability for the patient to see a specialist for definitive diagnosis and management is not possible. Playing at specialism by vicarious consulting is far inferior to the consultation between a specialist, with awareness of edge cases, non standard presentations, their own unknowns, and doesn’t allow the patient to question and understand the proposed treatment options and the expected improvement in their symptoms over time vs the side effects or risks of the treatments.

We are being asked to have a go at specialties where we have actively decided the patient requires another opinion. If this is the best the NHS can offer we really need to all resign en masse and accept the state input as only a top up voucher to the fees we charge.

David Church 15 May, 2024 1:06 pm

Is it a good idea ? Cut out all the wholistic patient-centred generalist knowledge and just let ‘A&G Navigators’ see the patients and refer them to A&G Consultants. What could go wrong?
Patients alternatively would have the choiuce of referring themselves direct to a Consultant in their chosen specialty, or A&E, whenever they feel it is needed.
Nobody will know what everybody else is doing, and nobody needs to, since it will be entirely up to patients to decide what to do. And we all know how much knowledge, skills, and experience they have, don’t we?
I have a rash on my leg – maybe I should go to an orthopaedic surgeon?
I have diarrhoea after starting Metformin – maybe I should book a total colonoscopy with a Gastroenterologist? Ah, but perhaps you should!

Centreground Centreground 15 May, 2024 1:09 pm

NHS England is a failed and increasingly dangerous umbrella organisation constituted by a range of individuals of varying backgrounds as we are all aware and which is itself proven over decades to be not fit for purpose . The individuals responsible for these bizarre aberrations need to be clearer about who it is actually making these precarious directives .

Barry Sullman 15 May, 2024 2:36 pm

Simon – I strongly agree with you. I have a sense of unease when I am asked to manage patients in the community on a few sentences of advice from the specialist. I feel exposed and cannot help thinking whether the patient is ultimately getting a poorer standard of care.

Not on your Nelly 15 May, 2024 2:43 pm

this is a loss loss for patients and GPS. It needs to stop straight away. There are so many risks with this and it will all fall back to GPs being responsible for any problems as the consultant has not seen the patients and based his guidance on the “information provided by the GP only”. Just say no. a complete sentence.

Turn out The Lights 15 May, 2024 9:43 pm

HSL the architect of arse roles was head of the RCGP so will likely be as successful eh.Helping in the destruction of primary care the irony.

Peter Jones 15 May, 2024 10:48 pm

A and G is only OK if it is completely voluntary on the part of the GP, who is the only person able to make the judgement re. direct referral or advice please.

Yes Man 16 May, 2024 1:30 pm

House of cards being built on a house of cards. Don’t worry it’s very sturdy just don’t sneeze 🤧

Richard Singleton 18 May, 2024 6:39 pm

Locally we can’t pick up the phone and speak to secondary care, it has to all go through A&G which can take weeks. As a consequence more patients are sent to hospital acutely which could be avoided. A&G has a place but at the GP’s discretion, not NHSE’s mandate. If this were to be forced on us I suspect we’d also be duped into taking medicolegal responsibility and again acute admissions will go up. Can’t see any of us staying in post when referrals are rejected and we’re liable for the consequences.