Dr Reva Gudi, GP and former Conservative parliamentary candidate, shares why she thinks the A&G incentive is flawed
Dear editor,
In all the numerous NHS plans I have seen over the last 30 years from successive governments, words such as ‘reform’, ‘investment’, and ‘genuine transformation’ make me think carefully about what this means for those of who use the NHS.
Let’s take investment, specifically. The Government has committed £22.6bn additional funding for the NHS over the next two years. This is within a hugely financially challenged environment, with many different priorities competing for attention.
The research on the effectiveness of financial incentives in healthcare has shown mixed results. Some studies suggest improvements in specific metrics, while others highlight the potential for unintended consequences. The ability of financial incentives to improve healthcare depends largely on how they are structured, implemented, and monitored, as well as the context in which they are applied.
Therefore, it is crucial that we think through every pound of taxpayers’ money that is spent. This is why the Government’s decision to allocate £80m for the extension of Advice and Guidance (A&G), offering GPs a financial incentive of £20 per request submitted to help manage elective care and reduce waiting lists, has left me both as a GP and a taxpayer scratching my head, and highly sceptical.
I am in favour of A&G; we must manage demand appropriately. This may or may not end with advice to refer to the hospital. By and large as GPs, we find A&G a helpful and supportive tool. It is well established across England, though there is disparity across the country.
So why am I against this offer of a financial incentive, and highly sceptical of what it is expected to deliver?
A&G is already ingrained in my everyday way of working as a GP and gatekeeper in the NHS. So I am baffled as to why I am being compensated with £20 per request, for a service that already fundamentally constitutes part of my existing responsibilities.
Currently I am using A&G where required, based on clinical judgement. Is the implication that paying me £20 per request is going to increase my number of requests? I should hope not. It is a perverse incentive that has the potential to drive unwanted behaviours. And if indeed, I am a GP who is not using a tool available to support me in my decision making, then that needs to be addressed by peers within the practice or commissioners – not by a payment of £20.
If I send in a A&G saying, ‘Dear Colleague, please see this patient who has had lower abdominal pain for 2 weeks’ (no other details) should I be paid £20 for this? The answer is no. That is an extreme example but you get my gist. This could become an unintended consequence of this financial incentive.
I also wonder how this initiative will be monitored. This £80m is being spent on a step which is part of a process where, in my view, there are no guarantees whatsoever of achieving what is proposed. Is this something we can afford? If the money were spent on addressing the gaps within the current service, and to ensure its availability across the country, I believe that would be a better use of funds. It would reduce variation, and more likely lead to a system wide impact.
I would also ask if my hospital colleagues have the capacity to cope with the extra workload that this may potentially generate. The RCGP rightly points out that if work is transferred from hospitals to primary care via A&G, then resources must follow the patient, and not stay in secondary care. That in itself is a separate conversation.
I am however a generalist and not a specialist. Just as I don’t expect my orthopaedic colleague at the hospital to manage a patient’s rash, I don’t expect to be asked to manage a patient with a condition that is best treated by a specialist.
The crucial question for me is: Do we have crystal clear clarity on how and where the taxpayer’s money is best spent, given the fact that health and social care demands are going up? Is it not imperative that we carefully think through investments, in the NHS, and whether they will truly deliver for the public?
Since 1955/56, spending on the NHS has increased by an average of 3.6% per year in real terms, masking substantial variation over time depending on the decisions made by the government of the day. NHS England’s budget now sits at £192 billion for 2025/2026.
Having witnessed the financial dynamics of the NHS in various roles – be it as a practicing GP, a commissioner, or a non-executive director in a large NHS trust – I have seen long term investment and thoughtful commissioning in our health system. Investments that have resulted in transformative and high-quality care that genuinely benefits patients by enhancing their experiences and improving health outcomes. I have seen great examples of productivity, efficiency and high quality care saving the NHS money. There are many successes across the country, small and big, because of the dedication and professionalism of those working in the NHS.
But sadly, I am also aware of the millions and billions of pounds spent on initiatives that fail to achieve their objectives, or areas where investment has been withheld. This is often because of short term thinking. The NHS is repeatedly burdened with new projects that, despite well-meaning intentions, are poorly executed and implemented, ultimately failing to deliver in the way it was imagined.
Meanwhile we have patients with lengthy waits in A&E corridors, newly qualified nurses struggling to find jobs, and patients on long waiting lists. The challenges are complex and many. You see the senselessness of it all, if I am to be brutally honest.
The encouraging truth is that there is money to be found. We just need to stop, think and open our minds to what is happening before our very eyes. And then act. I really think it is that simple.
Kind Regards,
Dr Reva Gudi
This GP’s love of A&G astounds me.
It has to be recognised that the not so underhand purpose of the incentive is a referral avoidance scheme for clinical conditions requiring confirmation of diagnosis and appropriate specialist management either consequent increase GP workload, snd potentially, clinically unsafe.
Our Practice’s experience is negative in the extreme. We simply get a stream of poorly judged clinical ‘recommendations’ listing esoteric (nn-GP, specialist) investigations, delayed diagnosis and poor patient care as a result.
As a patient, I would not be happy to have my complaint managed in this arm’s length manner by my GP. I wonder if GPs should seek patient consent for an A&G?
Nor has there been any robust published evidence that I am aware of demonstrating reduced referrals as many would end up as formal referral later on, perhaps by another GP in the practice.
Snd, Dr G’s many assertions are notable by absence of referenced evidence base.
blind leading Blind
Hello Dr Bhatt, Thank you for your thoughts. I neither love nor hate A&G but have found it useful by and large, and at least is a way to communicate with secondary care colleagues which has to be a good thing for our patients.(no more picking up the phone, which I preferred, but admittedly has its pros and cons) In any case, it is here to stay, from what I can see, and I completely agree, I too have my doubts as to whether it ultimately reduces referrals.and indeed whether it is going to have any impact on elective care and waiting lists despite an additional £80 million of tax payers money being thrown at it! Mind boggling