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.’
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