Dr Amanda Doyle: New A&G pathways do not impact a GP’s decision to refer
In an exclusive op-ed for Pulse, NHS England’s national director for primary care – and former GP partner – Dr Amanda Doyle sets out how the new advice and guidance system will function, and why it will help reduce GP bureaucracy
I’ve been asked a lot of questions by GPs about our approach to advice and guidance in the 2026/27 GP contract, with understandable concerns raised about workload or the ability to obtain specialist care for patients.
I want to take this opportunity to set out the thinking behind the change and why these new pathways will streamline care for patients and make it easier for GPs to get specialist advice with the minimum bureaucracy.
This will help to ensure referrers receive timely specialist advice, patients are directed to the most appropriate next step, and care is delivered in the most appropriate setting.
It could also avoid unnecessary appointments within secondary care while, importantly ensure that we recognise this means additional work in core general practice and therefore the additional funding to help deliver that work must be included in global sum.
An advice and guidance enhanced service for general practice was introduced in April 2025, supported by £80m in funding, to recognise the additional work that advice and guidance can generate for general practice teams.
Following near universal uptake of the enhanced service in 2025/26, the focus for 2026/27 is on stability and simplicity. Embedding advice and guidance in the core contract recognises it as routine clinical practice, removes annual signups, and provides more predictable funding while supporting consistent patient pathways.
Importantly, we are asking commissioners, providers and general practice teams to work together to agree prioritised referral pathways including use of single point of access once introduced.
GPs will submit referral requests via the e‑Referral Service to a single point of access. The decision on whether a patient requires an outpatient appointment, advice and guidance, or an alternative outcome, such as going direct for diagnostic tests will be determined through consultant‑led clinical triage.
Use of advice and guidance pathways and the introduction of a single point of access does not impact the referrer’s decision to refer.
Jess’s Rule will play an important patient‑safety role within the new system. It acts as a prompt for GPs to reflect, review and reconsider a patient’s presentation after repeated consultations, and to escalate for further investigation or specialist input where appropriate. It does not remove GP clinical judgement or create an automatic right to referral, but trusts will be expected to recognise when Jess’s Rule applies when undertaking clinical triage through single points of access.
Now that advice and guidance is a well-established across the country, with widespread uptake by general practice, it reflects the increasing confidence in its use and demonstrates that practices are routinely using it to support clinical decision-making and manage patients in the most appropriate setting.
Introducing a single point of access for referrals is a practical change that supports earlier specialist input, clearer decision-making, and safer patient pathways. It also means the onus is not on the GP to decide whether a referral should be for advice and guidance or an out patient appointment, or simply to obtain diagnostics that aren’t accessible in the community, whilst avoiding having to submit a separate claim for each request for advice and guidance, yet still receiving a full share of the funding via global sum.
Used well, it helps ensure patients are directed to the right care, at the right time, while respecting clinical judgement and strengthening the interface between general practice and specialist services.
It will only succeed if local GPs and specialist clinicians work together to make it work for their patients – which I know is what all of you want to see.
Dr Amanda Doyle is NHS England’s national director for primary care and community services
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READERS' COMMENTS [10]
Please note, only GPs are permitted to add comments to articles
There will still be a chunk of work bounced back
or
patients managed with advice and guidance, perhaps inappropriately, who would have benefited from seeing a consultant face to face
I appreciate secondary care has a backlog, but I’m not sure this is the correct way of dealing with it.
A&G is about GPs creating content, to establish a large training dataset, so that AI techs can write learning algorithms – in order that machine-learning AI can unemploy GPs out of this role in the near future. The same applies to online access for patients – content creation, training dataset generation, applying a learning algorithm.
This might well be the future for us but Dr Doyle, and other NHSE and DHSC bureaucrats, should be open about their real goals so we have an honest debate.
No one’s against AI, but some are against how it’s rolled out and sold to us (guardrails and ownership), and how the benefits will be distributed rather than captured by US Tech billionaires.
Dr Doyle addresses none of these issues, treating her former GP colleagues as ignorant, and merely does a job pushing IT “solutions”.
Working together? When told that A&G is actually referral, despite GPs who have been using A&G for decades knowing full well the conceptual and practical difference, we are being treated as ignorant and stupid.
Dr Doyle has failed to address obvious and fundamental considerations pertinant to collegiate and safe care: Accountability and responsibility for inevitable litigation when cracks are fallen through; the incontrovertible truth that decision-making involves reducing referral numbers being insidiously conflated with patients’ best interests; the (already well-evidenced delays and harms) from bouncebacks; the inability to simply refer a patient who undoubtedly needs to see a specialist.
Dr Doyle has failed to lead by example to engage with any sign of working together.
GPs are losing their right to refer. Denying such facts makes Dr Doyle look ignorant and a fool.
The specialists will quickly learn when I use A&G like the patients use our online form: “appt with specialist”, “appt with specialist”, “appt with specialist”
The “advice” is frequently unhelpful to say the least, as we all know. More nonsense from the zombie NHS England, the organisation that will not die.
Dear Dr Doyle
Nice in theory perhaps
Terrible in practise definitely
It is an absurd idea that will finally break general practice forever
Insulting to “lay out the thinking” after the event.
Embarrassing to lie to oneself about the say in this debacle one has actually had.
Disingenuous to claim this is evidence-based or good for any stakeholder other than secondary care.
Predictable results in patient outcomes and blame.
Hang your heads in shame those who have not listened and have overseen the death of primary care.
I cannot get my head around this concept of A&G ie a patient being assessed remotely without assessment by a specialist and being denied a hands on/face to face assessment!
I wonder how the medical defence insurance groups will handle the inevitable complaints if things go badly wrong as will inevitably happen.GPs are not specialists and AI is not able to see nuance.
If hospital services are so bad in spite of the large consultant expansion in the last 20 or so years then the entire system needs to be overhauled.
Height of galighting
the word ‘mendacious’ is not used enough ; ‘constructively dissembling with intent to damage people and systems’ ; ‘intending harm to people needing care and support’ are all phrases which may or not be pertinent