GPs in England will be paid £20 for undertaking advice and guidance (A&G) with hospital specialists, as part of a bid to bring down the elective waiting list.
The Government said the total £80m of funding for A&G will help prevent ‘unnecessary referrals’ with 800,000 more patients managed in primary rather than secondary care annually.
GPs will be expected to ‘increase uptake’ of A&G, making up to 4 million advice requests in 2025/26, up from 2.4 million in 2023/24.
Prime Minister Keir Starmer has this morning laid out his reforms as part of the new ‘elective reform plan’ which ‘sets out a whole system approach’ to meeting the 18-week referral to treatment target by the end of this Parliament.
The plan also includes an ambition for GPs to refer more patients directly for diagnostics for conditions such as breathlessness, asthma in children, and post-menopausal bleeding.
This will remove the need for patients to see a consultant first, and will ‘end the cycle’ of patients ‘getting stuck’ between GP referrals and hospital appointments, NHS England said.
Sir Keir indicated that the expansion of advice and guidance is part of the Government’s oft-cited aim to shift care from hospitals to the community.
‘If we can get more GPs consulting immediately with specialists diagnosing even more quickly, then we’ll avoid an extra 800,000 unnecessary referrals and appointments every single year,’ he said.
The Government said in its announcement this morning that ‘GPs will be funded to work with hospital doctors to get specialist advice before making referrals’.
And the Department of Health and Social Care (DHSC) confirmed that this funding will equate to £20 per A&G interaction, and the total funding package of £80m will come from existing secondary care budgets.
The full elective reform plan, published after Sir Keir’s speech, said NHS England will ‘ensure both primary and secondary care are funded to deliver Advice and Guidance, by splitting the existing elective tariff’.
Of the £20 per request payment, the plan said: ‘We expect this to increase uptake, with more patients benefitting from their GP accessing rapid specialist advice, so they receive the care they need in primary and community care settings, as opposed to being added to the elective waiting list.
‘This expansion will deliver up to 4 million advice requests from GPs in 2025/26 (up from 2.4 million in 2023/24), which we expect could increase diversions from elective care from 1.2 million in 2023/24 to 2 million in 2025/26.’
NHS England also said it will support ICBs to optimise A&G by ‘providing access to a range of metrics, dashboards and toolkits’.
The full elective plan aims to bring down the 7.5 million-strong waiting list, which is the Government’s ‘first step’ to deliver its NHS manifesto pledges.
Sir Keir also announced this morning a ‘new agreement that will expand the relationship between the NHS and the private healthcare sector’, allowing NHS hospitals to make more use of private facilities.
In summary: Reforms to bring down waiting lists
- Enable GPs to direct patients straight to diagnostic testing before having to see a specialist, so they receive tests quicker
- Expanded use of community diagnostic centres (CDCs)
- Opening the centres for longer – 12 hours every day, where possible
- Expanding the range of tests available
- Increased number of surgical hubs
- Ensure patients can get more information via the NHS App – details of appointments, results and waiting times
- Make more appointments available in the community instead of hospitals
- Treatment for five specialties experiencing particular pressures on the waiting lists will be made available outside of hospitals, including Ear, Nose and Throat services
- Publish minimum standards that patients should expect to experience in elective care
As part of GP collective action, the BMA advised practices to stop engaging with A&G pathways, and at the November English LMCs conference, local GP leaders recommended the same.
In November last year, NHS England said there will be no national mandate for GPs to use advice and guidance in a certain number of cases, and that local systems should design their own targets and processes.
But in June, Pulse revealed an NHS England document which confirmed that it wants to ‘optimise’ GP referrals to secondary care via an enhanced model of A&G.
The document encouraged local commissioners to ‘strengthen’ specialist advice services with an ‘advice and refer’ model which means all referrals or advice requests from GPs ‘come in through one route’.
Pulse previously reported on the success of North East London GPs in securing funding per ‘episode’ of A&G from their local commissioners.
However, Pulse revealed in July that the funding had been cut after GPs fell short of their ICB’s ‘required targets’.
In response to the Government’s announcement, the RCGP said A&G services ‘have the potential’ to support GPs to ‘refer appropriately’.
RCGP chair Professor Kamila Hawthorne continued: ‘But in the past GPs have reported issues with using A&G services, including that they shift care into general practice without appropriate resource and that they can be used to reject necessary referrals, so it’s encouraging that the A&G service is being looked at as part of the Government’s wider plan to reduce referral waiting times.’
She said the college is ‘pleased to see that general practice will be funded’ to increase A&G services, which will ‘help improve the referral experience for patients’.
But Professor Hawthorne added: ‘As ever, the devil will be in the detail, which we look forward to seeing – but this is a good step in enabling services to move out of hospitals and into the community, where care is more cost effective and where patients want to receive care.’
The Rebuild General Practice campaign said the Government’s measures today ‘do not address the critical GP shortage’ the profession is experiencing.
They said: ‘Decades of neglect have broken the entire system. We don’t have enough family doctors to treat our patients. GPs are leaving the profession in droves, and practices are closing all over the UK.
‘The Rebuild General Practice campaign welcomes government efforts to create greater patient choice and return care to the community, but without a clear focus on addressing resource and funding gaps, this new plan won’t allow Labour to cut waiting times as promised.’
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No. Just no. The usual minimal £20 which doesn’t even cover the time to do the referral, let alone read the reply, action the 100 suggestions and hold the risk. Just no.
I think we all know this is a token effort at best. £20 surely isn’t enough to cover the workload and not even close to the cost of an outpatient appointment.
I believe minimum costing for any hospital outpatient appointment starts at £150 so the £20 for A&G for somewhat insulting.
Agree £20 is insulting. We had system where referrals were vetted (not GP led) caused such a stink & were shite it was binned. As regards PMB the “direct” part pretty much exists already. So far friend with same is awaiting biopsy where might actually see someone with Dr/Mr in title. Not even had examination all just history, referal, USS. Oh forgot could have had USS via our community service but ICB scrapped that & sent to secondary care who don’t have capacity!
GP- please advise what needs doing with this patient?
Consultant- Please do following battery of blood test, correct any abnormalities, if not better then refer for MRI, if normal then take all the responsibility until patient dies or sues GP.
MDU has advised in past that responsibility of patient care lies with GP even if A&G goes wrong as consultant has NOT seen patient.
JS Not sure that’s correct a+g is covered by crown indemnity
Is it not a case of referring as normal, but use A+G for routine care for £20 each.
I.e. someone with a low calcium, abnormal pth, borderline vitamin D, abdominal cramps etc etc.
Refer to endocrinology as normal.
Someone else with no symptoms, veyr slightly low vit D and the rest of the blood fine:
– Dear endocrinology, I was going to suggest this patietn takes otc vitamin D, do you think that is correct? please send reply on a crisp £20 note.
The correct solution is to have enough of the right professionals and treat professionals, well….. professionally.
Any attempts to short circuit demand are just never going to work.
£20 – inadequate and insulting – not enough money to cover a single additional GP appointment.
It implies gps are referring unnecessarily. . When gp wants to refer , he wants to refer .
In my personal opinion it will change nothing. It will be as effective as triage where you spend same time as consultation.
The start of another RAT race. Fund gebrral pactice rather than making them chase the pennies… Or privatise it like the dentist.
Utterly derisory.
I wonder how this will work in areas where the majority of referrals are already via an A&G system and how they will stop GPs claiming £20 for silly overuse of A&G ‘Dear rheumatologist, shall I start this 80 year old with recent spinal fracture and osteoporosis on bisphosphonates’ etc
The ultimate Trojan horse.
A trivial teaser payment for years of unpaid work
Why the negativity?
Should be very easy to game this into a nice little earner.
Whether It’s a sensible use of taxpayer’s money is another matter.
£80 million for 800,000 patients is £100 per patient.
No prizes for guessing where the £80 per patient goes…
Surely the way to play this (as stated before) is that we submit A&G to confirm what we already know. Eg this ex smoker has had a cough for 6 weeks. Should I get a chest xray? With this approach I recon we could easily clock up £200 a day so £1k a week etc.
The issue is that if they want us to use this as intended ie to facilitate the management of more complex patients in primary care, we will need to be paid at least twice this to cover the additional clinical and admin work + overheads and add ons. Until then, I’m tempted to simply play the system.
Let’s wait for the outcome of final negotiations
£20 is too much. It should carry no payment at all. What matters is that A+G is a clinical decision not a financial one, and that it carries no compulsion, and that it is an alternative option (chosen by us) to referral. Quibbling about how much we get paid for it is to it’s the point. As usual.
CDCs like the Darzi centres did not manage to recruit sufficient respiratory nurses for their diagnostic tests. NICE not in touch with the reality on the ground. We can have aspirations but the resources and staffing need to match it. Otherwise it just causes unhappy patients and stressed staff.
Quantitate figures indicate that inexperienced and risk averse GPs make the greatest number of A&G requests as well as the greatest number of referrals and investigation requests. Consultants try and cover all bases when they receive an A&G request so this generates huge amounts of extra work and cost. The more investigations a patient undergoes, the more likely they will then need to be seen in secondary care or need a further A&G request for a detected “abnormality”. Has anyone read a book called Catch 22 or another book called 1984?
This is akin to the £1 per Notification of infectious disease form, which is mandatory, and about to be expanded to chickenpox. (Separate question, but will mothers who have not heard about this be sent to prison for failing to Notify?)
I am not confident that there are many hospital consultants who are that happy to do this without seeing patient, so it is likely:
1) there will be disagreements between the A&G consultant and the local one, about individual patients; This is wasteful of GP time, and only ‘delays’ the relevant date for counting the referral;
2) The removal of th eability to phone and speak to your own local consultant to ask for individualised guidance on a patient is contributing to expansion of waiting lists and referral numbers!;
3) The process only delays actual referral dates by a minimal amount, making insignificant diference, (unless – see 4);
4) Is the whole idea because it is more difficult to refuse a patient adequate examination and explanation in an F2F consultation than on an A&G paper-trail? , but will this not simple result in more complaints to GMC and MDOs about consultants declining rudely, and an increase in patients being refered as is their statutory right, for an NHS Second Opinion ?
5) what is the economic impact to GPs if we just write the referal, but have a junior admin staff send it to A&G and then ignore the response and send the real referral anyway?