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Two thirds of GPs say ‘advice and guidance’ is blocking patients who really need a referral

Two thirds of GPs say ‘advice and guidance’ is blocking patients who really need a referral

Exclusive Two thirds of GPs feel ‘advice and guidance’ is preventing patients who really need a referral to secondary care from getting one, according to the findings of a snapshot survey of Pulse readers.

Advice and guidance (A&G) services, which involve GPs accessing specialist advice before making a referral, have become a major part of NHS England’s plans for clearing the pandemic backlog.

But of the 366 GP survey respondents in England who said they had used advice and guidance, 68% said they felt the pathway is blocking necessary referrals.

The survey also found that of those 366 GPs who had used A&G services:

  • Around half (49%) said A&G was reducing referrals;
  • More than three-quarters (78%) said it was increasing their workload;
  • Just over half (60%) said it was requiring them to work beyond their competence;
  • Two-thirds (68%) said A&G was resulting in patients complaining because their wish to see a consultant had been diverted.

One GP who wished to remain anonymous commented: ‘An increasing number of referrals are being rejected for secondary care service pressure reasons rather than clinical need. [This] often duplicates GP admin work as we need to re-refer, rewriting the referral and/or enclosing further information or tests results in order to get a referral accepted.’

NHS England confirmed in April last year that its 2022/23 target of over 10% increased elective activity would predominantly be achieved through upping the use of GP advice and guidance.

This followed the Government’s elective recovery plan in February 2022, which said that GPs’ role in tackling the hospital backlog would focus on the use of A&G to avoid ‘unnecessary’ referrals to secondary care.

GPs commenting on the survey shared mixed feelings about the pathway, with some describing it as ‘a waste of time’ and other’s reporting a more positive experience.

Dr Alice Hodkinson, a GP in Cambridge, told Pulse it is useful to be able to ‘get advice on how to manage people in the community while waiting for an appointment’ but said the current demands on general practice make it ‘impossible’ to use A&G to its full benefit.

‘I think A&G is broadly a useful process to send all referrals. I am reassured that a consultant or experienced doctor should see all referrals, so that the patient is seen in the right clinic, something that really should happen in any case,’ she said.

She added: ‘Ideally GPs could be managing more of these complex conditions, with support of consultant A&G, which would add variety to our work. Sadly, there aren’t enough of us to do this with the overwhelming day-to-day demands on us.’

Another GP, who wished to remain anonymous, commented: ‘It’s a massive time drain keeping an eye on this. It adds clinical risk and delays care. Often you get messages back telling you to do a load of tests or provide more information – it’s draining.’

They added: ‘It’s a barrier to smooth patient care and in my experience creates more work and admin for GP and admin teams.’

A locum GP in South Yorkshire said: ‘Advice and guidance works reasonably well when it is generated by the GP. But sometimes a referral results in an advice and guidance response listing investigations, treatment, and repeat assessments to be done. This can be a huge transfer of work, there may be tests I can’t access or can’t interpret, and clinical responsibility is still with the GP, I think.’

Another GP who wished to remain anonymous said ‘quite a few’ specialties at their local trust mandated A&G, but they had ‘never had any guidance that disagreed with my own plan so far, which suggests it’s often a waste of time and effort and undermines patient confidence in their GP.’

RCGP chair Professor Kamila Hawthorne said Pulse’s findings chimed with what members had been telling the College and concerns it has been raising with the CQC, NHSE and the Government about how A&G is ‘preventing some patients from accessing the specialist care and services they need’.

She said: ‘When optional and used effectively, A&G can support GPs and their teams to deliver timely high-quality care to patients, and in some instances prevent long waits for specialist advice, but these findings highlight that unfortunately this is not always the case.

‘It is important that these concerns are addressed to ensure patients have access to the care and services they need within secondary care. There need to be solutions in place to ensure that A&G services are not adding to GP workload or forcing GPs to work beyond their level of competence.’

She added that it was ‘essential’ that primary care teams can continue to make direct referrals where appropriate and said the RCGP has called for A&G to be fully resourced within both primary and secondary care.

In March last year, Pulse reported that one LMC had secured GP funding for the extra workload caused by A&G requests, with GPs in North East London being funded £16.66 plus £2.50 for admin per request.

Meanwhile, in April, the Medical Defence Union warned GPs could be held liable for advice given to them by hospital colleagues about their patients via ‘advice and guidance’ services.

The survey was open between 23 November and 5 December 2022, collating responses using the SurveyMonkey tool. It featured a range of questions on various topics and GPs in England were asked to respond to these particular questions. The survey received over 1,000 responses in total, with 366 GPs answering this question on advice and guidance. It was advertised to our readers via our website and email newsletter, with a prize draw for an £250 John Lewis voucher as an incentive to complete the survey. The survey is unweighted, and we do not claim this to be scientific – only a snapshot of the GP population



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

Darren Tymens 25 January, 2023 9:50 am

Advice and Guidance = Shirk and Dump
The only form in which this should exist is as a simple mechanism for a GP to seek advice, and nothing more. Its single purpose should be as a communication tool.
Instead what hospitals are using it for is as a way of using us as community house officers to deliver the first parts of an outpatient pathway, whilst keeping the funding.
There is nothing in either our or the hospital contract that allows them to refuse referrals. Just clearly state if you are asking a question or asking for a referral – then insist and don’t accept any referral rejections or ‘helpful advice’ that involves extra workload or working beyond your competency.

David Turner 25 January, 2023 12:40 pm

Why are so many GPs commenting anonymously?
Please do not fear ‘them’. You have genuine concerns and these are received more forcefully when you put your name to them
The GMC cannot hammer you for expressing your opinion over a genuine concern..

For the record, I agree, A and G, is mostly worthless and a way of keeping patients off waiting lists and dumping secondary care work on to us.

Thomas Kelly 25 January, 2023 1:30 pm

I have found it useful in some circumstances. I have also been given advice to complete a number of investigations that are not possible in primary care and rediscuss after said investigations have been done. There are pros and cons. I also think the response is very dependent on the clinician. There are helpful consultants but I have also found responses that just palm you off without giving any advice apart from lots of tests. Maybe if the secondary care clinicians had some training on what the limitations were in primary care for investigations and resources, then it may be an improved service.

Sam Macphie 25 January, 2023 6:04 pm

I am not surprised two thirds of GPs think this is blocking patients who really need a referral. This is one of these schemes that is costing the country money and is often delaying care and efficiency for the rest of a GPs heavy patient workload and this is not wanted by GPs or patients. What a waste and mismanagement of NHSE resources: is Mandy Preachard listening? Good item and good doctors’ comments. Perverse scheme.

Mo Sul 25 January, 2023 8:02 pm

It is also a repeated occurrence that A&G is accepted as a referral or directed to send via C&B, only to receive a rejection a few days later.

Dave Haddock 25 January, 2023 8:49 pm

The NHS is increasingly devoted not to providing care, but obstructing access to care.

Turn out The Lights 25 January, 2023 9:30 pm

How many extra deaths a week again, and rising.

Sam G 25 January, 2023 9:33 pm

More pointless time wasting. Yet to have a single useful A&G response.

Sujoy Biswas 25 January, 2023 10:56 pm

It is a transfer of workload, liability and responsibility from one part of a failing system to another. It involves yet another communications interface that has to be monitored, and along with other contributors I rarely receive anything useful it is mainly more tests then refer

Michael Green 26 January, 2023 7:04 am

Hospital rejects referral – “talk to your GP”

Hospital places patient on waiting list – “talk to your GP for a letter”

Hospital cancels patient appointment – “talk to your GP to ‘book you an appointment’”

Hospital discharged patient after DNA (appointment letter is dated 2 days after fictitious appointment) – “talk to your GP for another letter”.

Hospital does tests – “talk to your GP for the results”

Hospital says “I have arranged follow up in 3 months time” but no appointment is forthcoming – “talk to your GP for a letter”

Consultant numbers up, GP numbers down, what is going on?

A Non 26 January, 2023 11:38 am

Proudly anonymous. For some fairly obvious reasons. If these require explanation I suspect you don’t actually need to know.

Giles Elrlngton 26 January, 2023 12:37 pm

I’ve spent hours trying to make A&G useful. I can see why some colleagues are unhappy with it, and to them I ask: how would you address the excess of referrals over clinic slots? More hospital doctors is the obvious answer but it’s not going to happen sufficiently. A&G is a sort of answer yes it’s imperfect but I’m not seeing any constructive suggestions here I am sorry to say. Accurate commissioning should be the answer but it doesn’t seem to be working.

Michael Green 27 January, 2023 7:50 am

It would help if the consultants did more than 1 clinic a week lasting 2.5 hours with 30 mins for new patients and 20 minutes for follow ups? And didn’t get their CNS to say TTYGP about every damn thing.

There are twice as many consultants as GPs already.

q b 28 January, 2023 9:27 am

Hi Giles.

I would say this:

If they are unhappy with our referrals then why don’t they go back to a time when GPs had an afternoon a month of protected learning where the super special hospital doctors taught us how they wanted to do things.
This has all fallen by the wayside and then they wonder why referrals are up.

Yesterday I wrote to radiology three times telling them to fuck off and take responsibility for the patient I requested scans on..their usual bullshit just didn’t wash as these were entirely appropriate scans (I’m talking USS, and one CT that we were told ‘GP to organise ‘ and I included the sodding letter saying so.

When will they realise we are not the enemy and if demand is too high then they need to be more transparent about what they’ll do…if they won’t replace hips and knees in fat people then TELL them yourself.

Truth Finder 31 January, 2023 4:18 pm

Anonymous as we do not trust the GMC. I encourage everyone else to be too. Work and the bug is being passed to us even on things we can hardly have an impact. The NHS has failed as it is doing too many social/police stuff and has lost the focus on medicine and treating diseases. We are being used as scape goats for a failed system.

Finola ONeill 24 February, 2023 5:46 pm

oh and public health, decent government; the real solution to the country’s health.
Obesity; the 21st century answer to smoking. Cause of the diabetes epidemic, resultant CVA/IHD, other diabetic complications, most elective hips and knees replacements (weight related), fatty liver (remember when that used to be alcohol; now everyone has it; because everyone is obese), etc, etc, etc.
What it needs=proper public health ie government response; similar to smoking. I remember learning at medical school the only significant thing to reduce smoking was the massive taxes and high cost (restricting where you could smoke in later years ie indoors etc helped also).
We need the government to ban advertising on fast food, processed food, super processed food, sugar, junk food etc.
And highly tax it with subsidies to unprocessed food; ie everything where the name of the food=it’s ingredients; ie ; fruit, veg, meat, milk, etc.
But the governments including ours are interested in supporting these industries and industrialised farming.
And in primary we get given the secondary and tertiary prevention to do for all the disease caused by obesity; useless.
I have told a million fat people and type 2 diabetics to eat less. It’s like telling smokers not to smoke. It is not a measure that works.
And pharmaceutical industries keep making new diabetic drugs, medical tech BM monitoring systems, etc; POINTLESS. WE NEED TO END THE OBESITY EPIDEMIC IN KIDS AND THE RESULTANT DIABETES AS THEIR PANCREASES FAIL AFTER YEARS OF FLOGGING FROM INSULIN RESISTANCE. and no government wants to tackle to root cause because proper healthy eating (cooking simple ingredients to make your own food) and healthy lifestyle (walking and cycling) DONT MAKE MONEY. AND OUR GOVERNMENTS ARE ONLY INTERESTED IN THEIR DONORS AND LOBBYISTS.
oh yeah and the marvellously important freedoms like eating yourself to death by non stop consumption of absolute crap.
And then telling us these LIFESTYLE issues are medical, the NHS’s problem, GP’s problem.
When the only ones that can fix them are government. Westminster.
Total and utter nonsense.

But sorry I have gone off on a total tangent.
Advice and Guidence. Also bullshit with an aim of jiggling waiting lists and nil else.

Faen Faen 19 March, 2023 10:46 pm

Sometimes is helpful advice, but depends on the consultant replying.