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A&G can help us raise standards, not lower them

A&G can help us raise standards, not lower them

Dr Stewart Hale argues that advice and guidance can be transformational when it comes to boosting clinical capacity and tackling patient wait lists 

Advice and guidance (A&G) is a hotly contested issue – and for good reason. As a key feature in most of the recent targets set by NHS England around elective recovery, it’s frequently top of the agenda.

Although its implementation is patchy, with varied outcomes as a result, we shouldn’t be too eager to dismiss A&G altogether because when implemented well, its impact can be transformational. 

Like any new measure that is parachuted in, A&G can cause more problems than it solves. It can unintentionally shift responsibility from one set of clinicians to another, often adding additional workload to already overburdened GPs. As a result, wait lists and elective recovery targets are pushed even further out of reach. 

But this isn’t always the case. When accompanied by structured support, onboarding and the right tools and resources, A&G can increase collaboration, streamline wait lists and boost GP capacity. 

To ensure these results are achieved all the time, we need to highlight the success stories and share best practice between individual trusts and ICSs, creating a blueprint for successful implementation. 

I’ve seen this work incredibly well within my ICS, NHS Cheshire and Merseyside, and the introduction of A&G to more than 100 GP practices in the region as part of a collaborative teledermatology project has already had a significant impact on helping tackle patient wait lists. 

In Liverpool, where the project began, use of A&G in dermatology is enabling at least half of cases submitted via the platform to be managed with A&G alone. Building on the success of this, it’s now being rolled out in other areas across the region. Working in close partnership with digital advice and guidance specialists Cinapsis, we’ve been able to introduce A&G into daily practice with minimal friction – and it is already having a notable impact. 

As I’ve started to work with other GPs in my area to support them with successful A&G adoption, I’ve found the following three considerations to be essential when it comes to introducing A&G in a sustainable, effective way:

Gradual roll-out

It might seem counterproductive but moving slowly when rolling out A&G can lead to faster results in the long-term. Starting with a pilot site, where comprehensive support can be focused and the infrastructure can be tailored to account for nuance, will help provide a solid foundation for incorporating A&G in a way that works for your individual trust or ICS. Results can be carefully analysed, and any necessary adaptations or adjustments made to the process before it is rolled out more widely across the region. 

Comprehensive onboarding support

Onboarding support can genuinely make or break the success of an A&G programme. Clinicians don’t have time to grapple with fiddly new systems or upskill on to new platforms alongside their daily workload. So, choosing a provider that can offer sustained, comprehensive onboarding support is absolutely crucial. This has been a huge factor in the success of the A&G rollout in Cheshire and Merseyside. External support, available from implementation and beyond, is enabling clinicians to swiftly adopt and benefit from the use of A&G, without adding any additional burden to their already full plates. 

Prioritising interoperability

A&G can truly unlock invaluable levels of collaboration across primary and secondary care. But if the system underpinning it is not interoperable and can’t directly share information or data with the other digital systems already in use, it will fail to deliver any meaningful improvement. Streamlining communication between primary and secondary care is key for A&G to successfully reduce workload and benefit clinicians and patients alike. So, ensuring the platform or tools you’re introducing to enable A&G are fully interoperable is essential. 

By pooling experience and best practice on A&G implementation, it can help to raise standards in primary care, rather than lower them. With the right support, infrastructure and roll-out in place, A&G can deliver significant results in terms of boosting clinical capacity and tackling patient wait lists. 

It’s not yet time to wave A&G goodbye; we must instead work collaboratively to ensure it can be successfully accessed and implemented in primary care services across the board. 

Dr Stewart Hale is a GP and clinical lead in Liverpool, who has been using the teledermatology pathway on the Cinapsis SmartReferrals platform to secure specialist advice on skin lesion cases



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

Mr Brown 15 March, 2023 3:35 pm

A&G absolutely has a role but only when the GP elects to use it.

However, it is currently mainly used for shunting ever more risk and work to GP’s and reducing access for our own patients even further.

Extra tests, extra GP and nurse appointments – none of it resourced. Buying a dermatoscope and some slow software does not count as support.

Peter Pulse GP Jobs User 15 March, 2023 3:40 pm

Sorry, I’m confused. If “at least half of cases submitted via the platform to be managed with A&G alone” presumably the resulting workload remains entirely in General Practice. How can this “boost GP capacity”?

David OHagan 15 March, 2023 3:47 pm

Sorry Dr Hale,
Cinapsis isn’t paying you enough for this…. (they get to keep their profits though)
and neither are the dermatologists…
The data isn’t available yet to show that it helps the patients or the dermatologists, and it will take longer to show how it really affects GPs.
Dermatology are not yet sure if it has increased or decreased their workload.

‘managed by A&G alone’ is not a good thing without the assurance of clinical experience and review.
The same dermatologists who will not allow GPs to remove lesions due to the limited quality assurance this entails are now discharging their responsibilities without even seeing patients.. seems they can’t make their minds up…

David Church 15 March, 2023 5:27 pm

There is a problem with analysis of the trial project that found 50% of submissions were managed by A&G alone without referral.
Up until not so very long ago, we used to be able to contact a local Consultant for a&g (deliberate Small Letters) when we wanted it to manage a case without referral.
More recently, for a while now, we have not been able to, (because hospital only gets to charge for ‘completed episodes of care’ that involved an OPD visit at the least.
Suddenly, we have a ‘choice’ of refer or A&G (Note the Big Letters now). It is most likely that GPs will submit through A&G those queries we would have (10-20 years ago) sought a&g on rather than a referral, especially in a rural area where patient transport to attend an OPD (the only available response to a ‘referral’ ) was punitive and often of little benefit over a&g.
So, the cases coming through A&G includes a significant proportion of ‘self-selected’ cases that are best suited to A&G.
This CANNOT be validly generalised to the referrals that we make NOT through A&G, where, in most cases, the GP has made an active decision to NOT use A&G.
Unfortunaetly, now, the A&G system is becoming a means to block access to referrals when GP and patient needs one, which will harm patients now, and, through putting off GPs, for a long time into the future also.
The other problem with A&G is that our local Consultants have much better knowledge of what services are available locally, and the difficulties involved in getting patients to a hospital 3-5 hours’ drive from home (if they drive, train takes 11 hours, not on Sundays). Not all of the Consultants providing A&G are local, and some do NOT know how to access services locally or what services ‘local’ hospitals and community services actually can provide.
This does increase burden on GPs significantly; and the process is far more costly in GP time than a phone call to an available Consultant or senior Junior Doctor, (such as an SR).

paul cundy 15 March, 2023 9:41 pm

Dear All,
Oh dear, after 34 yrs as a fiercely protagonist “gatekeeping GP” I worry for my personal care when i get a bit doddery, forgetful, have some swelling of my ankles, a few skin lesions that don’t rub off and the odd “palpitation”. If my care is going to be defined by a fully qualified independent practitioner whose abandoned that concept to simply follow rules applied by managers to secondary care consultants with targets to meet, then I’d feel the NHS I entered and have worked with has been sold down the line.
As a GP you are an independent contractor, an independent professional not bound by anything other than what is best for your patient.
For heavens sake, and all my cohorts sake, look up from your screens and see the light.
Paul C

paul cundy 15 March, 2023 10:00 pm

Dear All,
So the problem here is GPs referring barn door seb keratoses as “possible melanomas”. So in that aspect I agree it should be used, get those gatekeepers to be better at their job. I’ve had a retired GP insist I see his wife with a “melanoma” which turned out to be a keratin plug on a blackout.
Paul C

Darren Tymens 16 March, 2023 9:45 am

You don’t mention funding. I’m literally amazed it isn’t one of your three essential considerations.
Locally, all consultant time spent on A and G is fully funded and the consultants drop other work to sit in front of screens answering emails. It is acknowledged as work and rota’d into their sessions.
But there is no funding for the extra GP time spent managing either A and G or the extra workload associated with it. And there is no acceptance that we can drop clinical sessions to deliver it.
Until systems, and especially clinical leads who should really know better, stop treating general practice like a free all-you-can-eat- buffet, this is only going to get worse.
This is a purely secondary care problem whose solution is being imposed without funding on an already over-stretched general practice. It’s not even as if we are referring many more patients – numbers of referrals are still down on pre-covid levels. There are other solutions: imporve hospital capacity and productivity.

David Mummery 19 March, 2023 8:08 am

A&G can help lower standards and not raise them

Guy Wilkinson 24 March, 2023 2:06 pm

ICB Clinical Leads often develop Stockholm Syndrome