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Madvice and misguidance


fruit and veg prescription


So where do you head if you want advice and guidance? The pub? Your chosen deity? The Samaritans? Well, obviously, we all have the latter on speed dial for those Monday morning surgeries.  But wait. These days, ‘Advice and Guidance’ means something else: that increasingly widespread resource whereby we email consultants for, yes, advice and guidance – before, or instead of, a referral. 

The idea is to ‘improve communication’ and ‘smooth the patient journey’ yada yada, which sound great. But then so did the Titanic. Consider a simple A&G request recently sent to a local endocrinologist. The response advised and guided me towards a ‘GP to do’ list, which might save an outpatient appointment but only at the cost of tying me up in investigative knots for weeks. After which I’ll probably refer anyway.

And this is not an isolated incident. In practice, Advice and Guidance increasingly seems to translate as Diktat and Dump, with predictable effects on our workload and sanity.

Which is not quite how NHSE sees it. According to them, this is a win-win-win innovation – opening the lines of primary/secondary care communication GPs are always complaining about, facilitating high-quality care for patients and unclogging packed hospital clinics. What’s not to like?

Well, this. There is one final step down that A&G pathway that sooner or later must surely – and terrifyingly – be implemented. And what the NHS bureaucrats will do when that penny finally drops is breathtakingly simple. They will make A&G mandatory before every single non-two-week-wait referral.

Result? Referrals either blocked as ‘unnecessary’ or deferred until we’ve done the hospital’s donkey work. Genius. And the NHS suits could innocently and persuasively justify it thus: a) the queues for access to secondary care have to be sorted, and they stretch all the way back to your practice anyway; and b) as A&G is the kind of service GPs have always wanted and is self-evidently a Good Idea, we’re just making it universal and mandating its use.

Not only would this be a cynical way of dumping a massive amount of hospital work onto general practice while pretending to do the exact opposite, it would also formalise the current approach of hospitals viewing us as their unpaid community housemen.

Even worse, it will deal us GPs a massive and possibly fatal psychological blow. The ability to refer a patient is one of the few trump cards we have left. When we reach the end of our ability to manage a clinical situation, for whatever reason, a referral may well end up helping the patient – but the temporary relinquishing of responsibility certainly helps us. Not any more, if the A&G juggernaut thunders on towards its inevitable conclusion.

Imagine a world in which we cannot refer, and thereby make the patient Someone Else’s Problem. Yes, GPs are notorious for assuming the sky is going to fall on their heads, but on this one I’m with Dr Chicken Licken as it will be absolutely clucking awful. Don’t know how to cope? You could always ask Advice and Guidance. Actually, don’t bother.

Dr Tony Copperfield is a GP in Essex. Click here to read more of his blogs

READERS' COMMENTS [7]

Nigel Clark 1 October, 2021 5:40 pm

Spot on Tony! Keep doing this great work. I love your Advice and Guidance.

David Mummery 1 October, 2021 6:37 pm

A&G is a total con. It just keeps clinical the risk in Primary Care and GPs. We have always been able to get advice, you just pick up a phone and bleep someone ; we do not want advice, we want secondary care to see the patient , make a diagnosis, investigate and treat as appropriate ( and order their own investigations) and take on and equalise some of the clinical risk

Turn out The Lights 2 October, 2021 11:02 am

it is a con,expose the emperor,copy the patient into the letter back,let them see the croc of sh💩💩it is.

Andrew Taylor 2 October, 2021 12:21 pm

I normally laugh at your writing but I couldn’t even raise a smile with this article. Your imagined world is an absolute nightmare and could be closer than we think.
NHSE doesn’t understand general practice and seems to hate us as well. Not a great combination!

ANTHONY Roberts 4 October, 2021 2:18 pm

Copy the patient into the letters.
Make sure the consultant ‘s phone number is prominent and the patient is clearly advised to ring it if any further concerns.
Any blood requests send to the hospital phlebotomy clinic with a copy of the A and G advice.
Same for x ray requests.
When the hospitals squeal that they cannot cope politely point out that this is what consultant X advised and they should speak to them.

Patrufini Duffy 4 October, 2021 3:30 pm

What if you’re darn right clever enough to not need advice or guidance. If you can’t refer, you better just go home. It’s like a dentist who’s told not to do the filling, just extract. Actually, that’s what they do for “cost-effective” dental care isn’t it NK, then get back to their Botox and private implants and selling Oral-B?

q b 6 October, 2021 7:47 pm

The complete idiots running most ccgs have gotten rid of the monthly half day mandatory training you would have..the plt days…where you might get to learn from the horses’ mouth what they do and don’t want to see, and what can be handled easier in primary care .

If they say our referrals are shit then instead of getting us to do a+g, I’m happy to be reeducated in the protected learning time..