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NHS England told to provide local evidence of A&G effectiveness

NHS England told to provide local evidence of A&G effectiveness

An influential group of MPs has asked NHS England to provide evidence that use of ‘advice and guidance’ (A&G) services by GPs is effective in tackling the elective backlog.  

Last year’s elective recovery plan had stressed that GPs’ role in tackling the NHS hospital backlog would focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.

The recovery plan aimed for 1.7 million elective referrals to be avoided in this way in 2022/23, rising to 2 million in 2023/24.

A&G services involve GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.

But MPs from the Public Accounts Committee have said that the plan partly relies on initiatives, including A&G, ‘which have potential’ but for which there is so far ‘limited evidence of effectiveness.’

A report by the committee said: ‘NHSE has expanded some programmes because it believes them to be sufficiently promising, but there is currently a limited evidence base for their effectiveness, their impact on other parts of the health and social care system, and how they will work on a greatly expanded scale.

‘NHSE told us it would ensure that capacity in surgical hubs, community diagnostic centres and the independent sector would be genuinely additional.

‘However, it has more work to do to demonstrate how additional capacity will be sufficiently staffed without detracting from other NHS services.’

The National Audit Office (NAO) also warned against a reliance on passing more workload to GPs, pointing out that general practice itself is ‘under strain’ in November last year.

At the time, it said that while these programmes ‘may be based on good premises’, NHS England would ‘need to monitor carefully whether they are producing results in practice and build in proper evaluations as quickly as possible, being willing to re-direct resources as necessary to where they can have most impact’.

In its new report, the Public Accounts Committee said it is ‘concerning’ that NHSE could not provide the NAO with its full evaluation of the 2021 elective accelerators programme, on which it spent £160m.

The committee recommended that NHS England ‘should know more about the conditions necessary for individual programmes to make the greatest contribution possible to recovery.’

The PAC report added: ‘Alongside its Treasury Minute response to this report, it should write to us more fully describing the real-world impact of community diagnostic centres, surgical hubs, increased use of the independent sector, and the advice and guidance programme.

‘It should set out its understanding of the extent to which these initiatives have so far generated genuinely additional activity, rather than simply displacing activity elsewhere in the NHS.’

Dr Richard Vautrey, assistant secretary of Leeds LMC and former GPC chair, told Pulse that advice and guidance provided by a specialist when a GP specifically requests it can be very helpful when done well.

However, he added: ‘It must not by obligatory or be used as a barrier that prevents GPs from referring patients to secondary care services when they believe this is necessary as this could put patients at risk and adds further to the burden and risk carried by many GPs and practices. 

‘It’s unlikely to have a major impact on waiting lists for elective procedures as patients referred by GPs need to be seen by a specialist, and if A&G is used as a barrier to access specialist care there is the risk that waiting lists are made worse in the long term if a patient’s condition deteriorates because of delayed referral and treatment.’

Professor Azeem Majeed, professor of primary care and public health at Imperial College London, said there have been mixed reports about the benefits A&G.

He told Pulse: ‘It is important that NHS England commission an independent evaluation of the programme to see how well it is working and what areas need improvement. It’s difficult to comment on the programme until such an evaluation has been completed.’

In November, NHS England told the NAO it is ‘monitoring the impact’ of A&G on the GP workforce as well as on secondary care.

GPs have raised concerns about A&G acting as a barrier to appropriate referrals, as well as the extra workload involved.

Previously Pulse revealed that an LMC called for GP practices to be paid £12.50 per A&G episode to resource the extra workload.

It followed a major London trial assessing advice and guidance as the single point of access for referrals and a CCG target to cut GP referrals by 65% through A&G.

Last month, GPs raised concern about a new colorectal cancer pathway aimed at reducing referrals into one of England’s largest acute hospital trusts.



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

Truth Finder 1 March, 2023 9:39 am

No doubt we want to help but not at the expense of more patient and personal risks. They need to change the system’s blame culture. Not giving us sufficient staff or time and making us take unnecessary risks if pushing us abroad.

Nathaniel Dixon 1 March, 2023 10:18 am

In reality it’s often being used to delay care, create a few more hoops to jump through before we can refer and massage the figures a bit. In the long run delays are just causing more ill health and taking more appointments and interventions to provide care when it eventually comes. If the time spent trying to avoid work was actually spent working things would be a lot better. Too many barriers and too much bureaucracy sums up the current NHS.

Some" Bloke 1 March, 2023 10:44 am

has anyone refused going via AG route because we are not funded to do it?

Sam Macphie 1 March, 2023 11:21 am

Yes. Dr Vautrey sounds absolutely right. ‘A&G must not be obligatory or used as a barrier that prevents GPs from referring patients to secondary care services when they feel this is necessary as this could put patients at risk…’ Could the overzealous use of Advice & Guidance be one of several reasons why Hull University Teaching Hospitals NHS Trust is one of the worst performing for waits at A & E in the UK? Some patients end up at A and E at some stage as a result of diversions, delays and evolving critical situation. Also, why has Hull University Teaching Hospitals seen fit to spend time, effort, clinician-time in a different way, displaying A and E on national TV? is there a ‘money motive’ here, to help fund some services (perhaps ironically funding more A and G) with some sensationalist patients and others ‘acting up’ for the cameras? Who knows. Perhaps patients should be treated quietly, unobtrusively and respectfully with full 100% concentration, no diversions. Why make Hull A&E a ‘reality’ TV show? Unbelievable. Just concentrate on treating the good people of Hull efficiently and with care, (no TV sensationalism), and not blocking GPs who are committed to doing a good job throughout the UK.

Iain Chalmers 1 March, 2023 9:43 pm

Interesting issue locally 4% of local A&G converted to a 2WW

1) the same information is interpreted differently?

2) having noted this 10 weeks since requested further discussion with no response

Finola ONeill 2 March, 2023 1:45 pm

“A&G services involve GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.”
We don’t refer patients in for a “hospital investigation” we refer them in for a specialist opinion; that is the whole bloody point.
We need expertise; not a phone call, not a letter back, and not an investigation.
That is why surgical hubs and community diagnostics hubs won’t be a replacement either.
I have a plethora now of patients who are having scans done in general practice that won’t even be changing management; all those back or neck pains with no red flags; pelvic US with no real indication, etc.
And a bunch of perplexed patients that when I am the f/u after the scan have nothing extra to offer. It was never going to change management anyway.
One woman; 2 shoulder US and an MRU; both US months apart showing bursitis; no steroid injection, no change in analgesia meds; just imaging. crying and asking why does my GP keep imaging me and I am not getting any treatment.
It’s just fucking BS and we need to push back.
Keep referring. Decline the turfing back.
I manage what I am capable of managing; and stretching it a lot more now as we all are.
When I refer it is because I am out of ideas or time.
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