Background
GPs are expert generalists and have the unique ability to deal with undifferentiated care. This requires a wide breadth of knowledge but there are occasions when a GP will need to refer for a specialist review. This is normally as they either know what is wrong with the patient and that the treatment of this condition requires specialist or hospital-based care or they have significant concern about a patient but there is uncertainty about the underlying diagnosis and what treatment will be needed.
Traditionally, in both situations, the GP would refer to a specialist colleague who would then offer the patient an out-patient appointment for further review. Over the past few years, with the advent of the NHS electronic referral system (eRS) in 2015, A&G has become another option. A&G can be helpful, especially in situations where the GP knows what the issues are and needs some support in the management of the condition or is unsure as to the best way to further investigate or manage a problem.
In the past couple of years, some ICBs and hospital trusts have implemented systems so that all referrals need to be done via A&G rather than direct out-patient referral. This can prove to be problematic as it can delay a patient, who the GP knows needs specialist input, being seen in out-patients. The response to the A&G also has the potential to create further workload for the GP both in terms of additional consultations with the patient and arranging/following up on additional investigations.
What is A&G?
A&G is defined by NHS England as follows:
A&G is defined as non-face-to-face activity delivered by consultant-led services which can be:
- Synchronous (for example, a telephone call).
- Asynchronous (enabled electronically through eRS, or through other agreed IT platforms or email addresses).
By providing a digital communication channel, A&G allows a clinician (often in primary care) to seek advice from another (usually a specialist) prior to or instead of referral.
As stated above, the A&G approach is a move away from the traditional referral approach in which a GP would refer a patient to a consultant who would then see and assess the patient before giving advice on and/or instigating their management.
The often non-stated but important consequence of A&G is that it offers little respite for GPs in relation to holding the risk for the care of the patient, compromising their professional safety which should not be underestimated.
The pandemic accelerated the adoption of the A&G model, but concerns have been raised that the A&G approach may leave a GP vulnerable to criticism in the event of an adverse outcome.
Why is NHS England promoting the use of A&G?
The purported advantages of the A&G approach as stated by NHS England are:
“Growth in demand has meant that hospital outpatient visits have increased significantly over the past decade. The NHS Long Term Plan includes a commitment to redesign outpatient services so that patients will be able to avoid up to a third of face-to-face outpatient appointments over the next five years. This will remove the need for up to 30 million outpatient visits a year; saving patients time and improving their experience.
“Mobilising A&G services will help transform the way referrals are managed by improving the interface and facilitating shared decision making between primary and secondary care. Through better enabled communication, A&G provides GPs with access to consultant advice on investigations, interventions, and potential referrals. This helps manage non-urgent (elective) patients in the most appropriate setting, helping reduce unnecessary referrals into secondary care.”
NHS England also state:
“By providing a digital communication channel, A&G allows a clinician (often in primary care) to seek advice from another (usually a specialist) prior to or instead of referral. Reasons why a clinician may wish to seek advice and guidance include:
- Asking another clinician or specialist for their advice on a treatment plan.
- Asking for clarification regarding a patient’s test results.
- Seeking advice on the appropriateness of a referral.
- Identifying the most clinically appropriate service to refer a patient into.”
GMC guidance on referrals
The GMC guidance Good Medical Practice states that you must recognise and work within the limits of your competence (Domain 1 (2)) and that in providing clinical care you must refer a patient to another suitably qualified practitioner when this serves their needs (Domain 1 (7h)). Both requirements place a duty to refer appropriately but do not specify any referral pathway.
Good Medical Practice states that you must make good use of the resources available to you, and provide the best service possible, taking account of your responsibilities to patients and the wider population (Domain 1(14)).
A&G is a resource open to GPs to utilise, but consideration would need to be given to the impact of the additional work it creates on a GPs ability to safely care for all their patient population.
Building on Good Medical Practice is the GMS standards on delegation and referrals. This describes the professional standards which should be considered both by the referrer and the accepting clinician.
When accepting responsibility for delegated tasks, the standards state that you must prioritise patient safety over other considerations such as training opportunities or performance assessments (paragraph 12).
In addition, paragraph 13 states that, you must make sure you:
- Understand what you are being asked to do, by when, and ask questions if you do not.
- Are capable of carrying out the delegated task, under supervision where necessary.
- Have an understanding of the patient, which may involve reading notes and reviewing test results where applicable.
GMS Contract Regulations relating to referrals
GMS Regulations 2015, part 5, clause 17 relates to essential services.
Included in this is subclause 6, which states:
(6) The services described in this paragraph are the provision of appropriate ongoing treatment and care to all of the contractor’s registered patients and temporary residents taking account of their specific needs including—
(a) advice in connection with the patient’s health and relevant health promotion advice; and
(b) the referral of a patient for other services under the Act.
This places a contractual obligation on the contract holder to refer a patient to another service. It makes no comment on the mechanism or type of referral.
NHS England eRS guidance
The BMA GPC England and NHS England produced joint guidance on eRS and the use of A&G in 2018. This is a guidance document and as such does not create either a professional or contractual obligation to using A&G.
Issue of additional workload
It has been recognised that A&G creates an additional workload burden on practices. In some areas this has been resourced so that the workforce can be funded to address this workload without having to reduce the capacity for other aspects of patient care.
Funding for this is not across all ICBs and in others is now being withdrawn. As an example, the North East London Advice, Guidance and Referral local improvement scheme (LIS) was contracted from 1/4/2023 until 31/3/2024 and is not being continued.
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.
The LMC would argue that this goes against the specialists GMC responsibility to treat colleagues with respect and help to create an environment that is compassionate, supportive, and fair and more importantly it does not make the care of patients the first concern but rather puts the needs of the hospital in managing waiting lists as the first concern.
Indemnity
It is important that GPs have indemnity that covers both clinical negligence claims and non-claims matters (such as a GMC referral, a complaint, an inquest etc) that may arise from the use of A&G.
Claims in NHS primary care relating to incidents that occurred after 1 April 2019 will fall under the provisions of the Clinical Negligence Scheme for General Practice (CNSGP), further details of which can be found here.
GPs should retain membership of a medical defence organisation (or equivalent) in relation to non-claims matters.
LMC advice
As outlined in this guidance, the use of A&G is neither a contractual nor professional obligation. If eRS only enables referrals to some trusts being via the advice route. If for these trusts, the GP requires specialist review and not advice, they should provide the full information required for a referral and state that the request is for the specialist to provide the patient with a consultation and is not a request for advice.
It was previously agreed between some of the ICBs who introduced a LIS and LMCs that, if the requested stated that this was for referral and not for advice then the patient would be provided with a specialist consultation, hence the attempt in some ICBs, to rename the system Advice and Referral. Most trusts should agree to this approach.
If despite requesting an appointment, the GP is then offered advice from the specialist, if they are not satisfied with this, they should respond stating ‘The original request was for a referral to <specialist team>, it was not a request for advice. As such, please provide this patient with an out-patient appointment as is their right under section SC6 of the NHS standard contract 2024.
Summary
The key overarching principles are as follows:
- The care of the patient should be the first concern for both the GP and the consultant.
- The patient should be at the centre of the decision-making process.
- It is important to develop and maintain good working relationships and lines of communication with our secondary care colleagues.
- If there is an adverse outcome, then (in relation to a claim) the test that will be applied will be – Did the GP act logically and reasonably (in accordance with a competent body of GPs faced by the same circumstances)?
- It is important to follow the principles set out in Good medical practice and other related professional guidance.
- If there are any concerns or doubts about the A&G, then seek further advice from the consultant.
- If the patient deteriorates and/or develops red flag symptoms, appropriate action must be taken, which may include but would not be limited to revisiting the A&G with the consultant.
- Make thorough and contemporaneous records.
- If you do not want advice on how to manage the patient’s condition but there is no direct referral mechanism available for the trust, clearly state within the referral letter that this is a referral for the patient to be consulted by the specialist team and is not a request for management advice.
Appendix A: what are the medicolegal risks for GPs and how can they be mitigated?
Whilst A&G is here to stay and does have advantages over the traditional referral model in some circumstances, it does carry some risks for the referring GP.
The potential risks (together with suggestions as to how they could be mitigated) include (but may not be limited to):
1. The consultant making an erroneous diagnosis and/or suggesting an inappropriate management plan based on a GP not providing all the relevant information.
Comment – this is undoubtedly a risk, and a GP does have a professional obligation to provide all the relevant information when making a referral. The consultant would have a professional obligation to request any relevant clarification (albeit there is a difference between missing information and inaccurate information).
Mitigation – the referring GP should provide the consultant with all relevant information in an accurate form and use the appropriate referral template (where relevant).
2. A disagreement with the consultant’s diagnosis or management plan remaining unresolved.
Comment – the referring GP may have reasonable concerns about a consultant’s diagnosis and/or management plan (this could be based on their wider knowledge of the patient or for other reasons) which could be detrimental to the patient.
Mitigation – the GP should raise their concerns with the consultant in order that a mutual understanding as to the approach that serves the best interests of the patients is reached.
3.The consultant makes a request that falls outside field of expertise and or the gift of the referring GP.
Comment – the issue speaks for itself.
Mitigation – the GP should raise their concerns directly with the consultant and the consultant should follow the guidance in agreed shared care protocols (should they be in place for the condition in question).
4.The GP does not follow the A&G.
Comment – this would leave the referring GP (and/or their practice) vulnerable if the A&G was not followed (without reasonable reason).
Mitigation – the practice should have in place procedures by which the A&G is followed-up. If it is not possible to follow the A&G for whatever reason, then the GP should consider seeking further advice from the consultant.
5.The patient suffers an adverse outcome even though the GP followed the A&G.
Comment – the issue speaks for itself.
Mitigation – if the GP provided all the relevant information in accurate form to the consultant and followed the A&G but the patient still suffered an adverse outcome then it is unlikely that the GP would be legitimately criticised unless they overlooked new red flag symptoms and/or failed to act upon them.
6. The patient does not comply with A&G and suffers an adverse outcome.
Comment – the issue speaks for itself.
Mitigation – detailed guidance as to how to approach the non-compliant patient can be found at the below link (the GMC guidance has been updated since the article was published but the basic principles remain intact).
Dealing with non-compliant patients
Declaration – Dr Richard Stacey, Medical Director, GP Support Team, Londonwide LMCs authored this guidance when he was working at the Medical Protection Society.
The GP should try and understand why the patient does not wish to follow the A&G (they may have reasonable reasons for not wishing to do so) and might wish to seek further advice from the consultant to see if the A&G could be adapted.
Ultimately, if the patient makes an informed, competent decision to decline to follow some or all of the A&G, then it is unlikely that the GP (or the consultant come to that) will be legitimately criticised (with the usual caveat that all the issues around the patient’s decision are fully and contemporaneously documented).
7. The consultant’s A&G is provided in the context of a telephone conversation and is misunderstood by the GP.
Comment – this is a legitimate concern.
Mitigation – at the conclusion of the discussion with the consultant, it is helpful to recap the A&G so that it is mutually understood. The GP should make a contemporaneous record of the discussion and the A&G provided by the consultant.
The GP could call the consultant back if unsure and/or ask if the consultant could confirm their advice in writing.