GPs in one area will no longer be funded to process advice and guidance (A&G) after falling short of their ICB’s ‘required targets’.
Following lobbying from the LMC in 2022, North East London (NEL) CCG agreed to pay roughly £19 per A&G request in order to cover the extra work that comes back to GPs as a result of actioning specialist advice.
This funding was carried over for Tower Hamlets, Newham and Waltham Forest when the ICB was established later in the year, and the project developed into ‘advice and refer’ whereby all referrals went through a ‘single point of access’.
Pulse reported last month that GP leaders feared NHS England wants to replace the traditional direct referral system, with ICBs being encouraged to take up the ‘advice and refer’ system across England.
And an NHS document confirming the plans, and setting out details for their recommendations to ICBs, carried no suggestions practices should be paid to carry out the extra work.
According to GPs in East London, the paid advice-and-refer system has worked well, but the ICB has now pulled the funding for this financial year, arguing that it was ‘non-recurrent’.
Local commissioners told Pulse that a ‘majority of practices’ had failed to meet targets for the project, which had resulted in ‘mixed achievements’.
Professor Sir Sam Everington, a GP in Tower Hamlets, told Pulse that he is ‘busy arguing back’ since he believes the funded advice and referral system has been a ‘fantastic success’.
He said: ‘There are two solutions to the waiting list, one is increased capacity in the acute sector. But secondly, supporting primary care to manage these patients in primary care – and we did that through funding.
‘It was about £100,000. It was non-recurrent funding, but it’s not been continued and I’m taking that up with the ICB at the moment.’
Tower Hamlets LMC chair Dr Jackie Applebee told Pulse that practices have been ‘unfunded’ for nearly three months since the start of the financial year.
‘The LMC has protested to the ICB and also advising practices not to use advice and refer as we aren’t contracted to, and to write in the advice box that we are not asking for advice but referring the patient to be seen,’ she said.
Recent guidance from Londonwide LMCs cited NEL as an area where funding for A&G has been ‘withdrawn’, with the local improvement scheme (LIS) having been discontinued this year.
The guidance added: ‘In areas where it is being withdrawn this is further complicated in that the secondary care trusts have redesigned their referral processes, so that all referrals need to be via A&G and they no longer have appointments on eRS for direct referral.’
According to Tower Hamlets LMC, there have also been issues with GP practices receiving payments for advice that was processed prior to the end of the contract.
The latest newsletter said: ‘The LMC has been pushing for some time to ensure that payments already due under the Advice & Referral LIS are made.
‘The ICB has in response done work to identify payments owed, which are to be checked and then approved – progress was promised very soon.’
NEL ICB told Pulse that as of 31 March this year, the contracts for advice and referral across the area ‘expired’.
A spokesperson said: ‘During the lifetime of the contract, the delivery of the scheme resulted in mixed achievements whereby a majority of practices did not meet the required targets.
‘The ICB is planning to work with stakeholders to conduct an independent evaluation of the A&R scheme. The remaining funds from the original non-recurrent funding will be ring-fenced for investment in primary care.’
GPs stopping to engage with the advice and guidance pathway is one of the options on the BMA’s current collective action ballot.
In November, 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.
Last year, Pulse’s analysis of how A&G is being used across the country found that GPs are concerned about the increased workload it brings, the medicolegal implications, and the lack of resourcing in primary care.
Note: This article was updated at 16.05 on 12 July to remove a claim that the ICB had also cut funding for phlebotomy in general practice. This claim was put to the ICB before publication and was not corrected. However the ICB has since confirmed that phlebotomy services have not been cut.
The ICB 2023 strategy was to expand Advice and Guidance into every practice in the ICB. Most people recognise that up to 65% of referrals can be managed through advice and guidance. This means that patient problems can be sorted typically within one week, rather than months languishing (irreversible deterioration in health and death) on a waiting list. The waiting list can be significantly reduced by supporting primary care in this endeavour, at a fraction of the cost of managing the problem in hospitals. The majority of referrals in Tower Hamlets are now being managed by advice and guidance. Pulling this funding is a disaster for patient care. For the ICB to claim that the majority of practices have failed to achieve high rates of advice and guidance is a travesty of the reality on the ground.
Phlebotomy has been resourced in general practice in part of the ICB for many years but NOT in significant numbers of general practice within the ICB. This service provided in every practice can significantly support patient care and reduce waiting lists. It should be a basic right of any patient. Sam Everington
‘There are two solutions to the waiting list, one is increased capacity in the acute sector. But secondly, supporting primary care to manage these patients in primary care’
– Actually, there are three. The third would be for hospitals to improve their efficiency and productivity, which has been on a downward spiral for years and collapsed over Covid. If hospitals were as efficient and productive as general practice partnerships then there would be no waiting lists and no overspends.
Not funded = fruitless labour by GPs. Looks like the (ever unaccountable) managing class continues to treat GPs like Sisyphus. Every time GPs nearly crest the hill (this time of a+g), the managers send them tumbling back down!
Time to make the NHS managing class more accountable for their decisions. If they truly had “skin in the game”, they wouldn’t make perverse decisions. And if they did, they’d personally pay for it (rather than be moved sideways).
A further point:
Although some funding is better than no funding, £19 is an inadequte amount to cover the work that bounces back from advice and guidance (or advice and refer). Typically a response involves organising a series of tests or treatments, then reassessing the patient before reconsidering next steps. A minimum of 2 GP appointments should therefore be funded – so the funding should be around £90, and not £19.
Furthermore, under PBR this would have taken two outpatient appointments and cost the commissioner around £400. £90 spent to deliver the same care in general practice would still represent over 75% savings. This should be a no-brainer, but under CCGs such disinvestment from hospitals in order to reinvest in more productive and efficicent parts of the system were continually sabotaged by hospitals and NHS managers (e.g. ‘we must not destabilise the hospitals’). Under ICBs – which are almost all utterly dominated by hospitals – this is now effectively impossible, as hospitals are on block contracts that allow them to keep the funding whilst dumping the actual work on general practice through mechanisms like Advice and Refer (or ‘Shirk and Dump’ as it has been called).
Wes appears to have committed to increasing the funding of general practice, which is great, but he will have one hell of a challenge to do this as the hospitals will not want to reduce their funding in the interests of the wider system.
A+G can not and must not replace the right to refer Nor should referrals be sent back with advice and guidance even when GPs insist on a consultation It has a place but not if its compulsory Consultant colleagues tell me that they just want to see patients in a well-run system. They don’t want to be pulled off outpatients or wards in order sit in front of a screen ping-ponging emails backwards and forwards with GP colleagues about patients they haven’t assessed properly. Who carries the risk and the responsibility Sorry to say but in addition to Covid other reasons for huge backlog in 2′ care include PBR being replaced by block contracts. Another trojan horse sadly with funding dangled and then pulled for spurious reasons-one way to improve referral thresholds is decent guidance across health economies Look at the excellent Kernow Referral Management Service
Classic commission bait and switch. £100,000 has bought the system 15 more years of unfunded increased ‘Gp to do’. Every complaint about this will be met by ‘soz Gp commissioners said we can’t accept face to face referrals’ until those administrators or clinicians retire or move away.
The fundamental issue across the NHS as a whole remains and is a major reason including the effect on funding why no one is yet able to find a solution to reforming the NHS.
The wrong individuals -inept GPs, nurses , admin staff etc. have managed to navigate their way onto ICB boards, PCN CD or manager roles , NHSE roles and additionally into some LMC positions again with some notable exceptions.
These are people who crave status, financial self-gratification and want these positions for self-interest but can be clearly seen to be unsuitable.
The groups who would state this is causing internal conflict within primary care itself are those in my opinion who are often part of this self-indulgent group, and it is a necessary step to address this problem which is a significant foundational source of NHS failures.
Ludicrous decisions will continue ad infinitum and as with any cancer unless this core problem is excised or removed by other means , it will eventually lead to the death of the NHS.
Classic NHS logic. There is no problem that cannot be made worse by these congenital morons.
What were the unmet ‘tarfets’?
Playing devil’s advocate here, if we refuse to engage with advice and guidance, so instead of getting a quick reply which generates a single contact, instead we just refer and the patient is more worried because they require specialist input but the appointment isn’t for 12 months, how many more primary care contacts is that going to generate?