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A&G is an acceptance of slipping standards

A&G is an acceptance of slipping standards

Jaimie Kaffash says that advice and guidance is an example of how we are accepting worsening standards within the health service

While doing a bit of research for the March issue of Pulse, I took a bit of a trip down memory lane and looked back at the GP Forward View. For the youngsters among you, this was a plan introduced in those heady days of 2016, which looks like a utopia for general practice from our 2023 viewpoint.

The one part that really struck me was around reducing ‘workload dump’, specifically where consultants send patients back to GPs to be re-referred to another part of the hospital. It won’t be a shock that this never happened. Indeed, not only are trusts still sending patients back for re-referrals, they are finding more and more ingenious ways of refusing referrals and piling work on to GPs.

The most ingenious way is one approved by NHS England for rollout across the country – advice and guidance (A&G), which raises thresholds for referrals, instead keeping the patients under the care of GPs, who have access to specialist support on the phone.

For GPs, the workload aspects of A&G have dominated the discussion, and understandably so. There is a definite reason for trying to cut referrals as secondary care is under just as much pressure as general practice. But all this does is shift workload from one part of the system that can’t cope to another that can’t cope.

But for me, the most egregious problem with A&G is more fundamental. I have argued many a time before, the NHS won’t ‘collapse’ – it’ll just see worsening standards, and us accepting it. A&G is a perfect example, as GPs in Lincolnshire have pointed out this week (and as GP respondents to a Pulse survey said too).

We know what GPs’ skills are (and they are something not always appreciated). But, by definition, their skills are not managing patients who they feel need to see a specialist. There is so much talk from ministers and in the media about GPs not seeing patients face to face, yet little uproar around patients being prevented from getting an appointment with a specialist that a medical professional has deemed is necessary. 

But I will leave you with a twist. Because, even when NHS England was purportedly trying to reduce GP workload (and claiming to raise standards), in the GP Forward View, they wrote this: ‘NHS England has established a Rapid Testing Programme in three sites across the country to review ways of better managing outpatient demand. This will include assessment of the practical application of consultant hotline and advice services, enabling GPs to get rapid advice rather than referring the patient.’

Shifting work to GPs isn’t solely a consequence of the pressure on secondary care – it was the plan all along. And GPs and patients are the ones suffering.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at



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

Thomas Robinson 26 February, 2023 8:48 pm

“We know what GPs’ skills are (and they are something not always appreciated). But, by definition, their skills are not managing patients who they feel need to see a specialist”
As always, well written and incisive. However, whilst not wishing to comment, may I advise that should you choose to persue this theme;
Your thoughts as to whether the GP could in fact manage the patient himself, given the time, resources, and above all investigation facilities afforded to the specialist would be most enlightening.

Dave Haddock 27 February, 2023 5:21 pm

This deserves more publicity. It’s from Cochrane, so difficult to dismiss with the usual abuse.

Do physical measures such as hand-washing or wearing masks stop or slow down the spread of respiratory viruses?

Published: 30 January 2023. Authors: Jefferson T, Dooley L, et al.

“The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks”.

The widespread enforcement of mask wearing during the Covid pandemic was not science based.

Anonymous 3 November, 2023 6:12 am

Another piece from the same editor slacking off A&G. I do wonder what is it exactly that he hates about them. A&G seems to be very much the go to when the patient comes back for a third time with the same issue.