Pulse editor Jaimie Kaffash warns that NHS England’s drive to increase the use of advice and guidance undermines and overloads GPs
There’s a scene from the golden years of The Simpsons that I often quote in my head. Marge is telling Homer why getting an elephant as a pet is a bad idea. ‘In theory, I agree with you Marge,’ replies Homer. ‘But in theory, communism works.’
This is a quote that seems particularly apt for advice and guidance. In theory, it works. But in reality, it is as inconvenient as a pet elephant.
Giving GPs a direct line to specialists to discuss borderline cases would benefit everyone. For patients, it would offer reassurance and save a lot of time and potential anxiety. For GPs, it would remove the many hours spent hanging on the phone when all they need is a second opinion from a specialist. And for secondary care, it would reduce referrals.
We will see more A&G in the coming years – there is no doubt about this. The group tasked with taking it forward will take a ‘patient-focused approach’, says the Royal College of Physicians, which is leading on it. A ‘patient-focused’ approach to A&G is possible, and it would look very similar to a GP-focused one: allowing the GP to decide with the patient if referral is necessary, and when A&G would be more appropriate.
But this is not what is happening. Instead, we’re seeing a secondary care-focused approach, where reducing waiting lists is the priority. GPs and patients aren’t partners in decisions: referrals are being sent back with advice and guidance, even when GPs recommend face-to-face appointments. In some areas, A&G is becoming a prerequisite before a referral – even if this isn’t yet official policy.
First of all, this is insulting to GPs’ professionalism. To some outside general practice (and I include ministers and some within NHS England here), this might seem counterintuitive – after all, they are entrusting GPs with more responsibility. But it undermines one of the main skills of a GP: knowing when to refer. GPs don’t refer for the sake of it. They refer because, in their expert opinion, that patient needs direct contact with a specialist.
Putting up barriers to this contact – which is what A&G does in practice – has patient safety implications, and is entirely in keeping with the NHS in 2023. The strategy to deal with backlogs is to make people practise beyond their skills and knowledge, whether that’s GPs taking on the responsibilities of specialists or physician associates doing the work of GPs. And the medicolegal implications can be quietly swept under the carpet until something goes horribly wrong.
It also (surprise, surprise) increases GP workload. Patients for whom responsibility would have to passed secondary care after a referral now remain the responsibility of the GP. With it comes admin time spent chasing results, on top of the extra consultations to relay advice from specialists to the patient.
The concept of A&G has been around for a decade. But, like most good-in-theory NHS schemes, it has taken the worst possible approach. So here is my advice. If we no longer care about whether a healthcare professional is adequately trained to manage a patient, let’s cut out the middlemen and have physician associates overseeing patients on the A&G pathway. At least then GPs can do the jobs they are trained to do.
But that would reveal that all we care about are secondary care waiting lists. And we can never acknowledge that (pet) elephant in the room.