The right to refer has become a central flashpoint in the most recent spat between NHS England and 38,000-odd GPs.
England’s national director for primary care and community services has walked back rhetoric around the NHS advice and guidance scheme, a model which some wish to see duplicated in Australia.
Advice and guidance (A&G) was first introduced in 2015 as an optional secondary referral system. It allows GPs to seek advice from a hospital-based specialist prior to referring a patient.
The model was largely uncontroversial until the latest round of contract negotiations between NHS England and the British Medical Association, which represents around 38,000 GPs working in the NHS.
Under the latest draft GP contract, GPs would be forced to consult a non-GP specialist via advice and guidance before referring a patient to any one of 10 as-yet-unnamed specialties.
The initiative is part of a broader aim to divert at least 25% of GP referrals to those 10 specialties by March 2027, called single points of access (SPoA).
Many GPs, including BMA GP chair Dr Katie Bramall-Stainer, saw the proposal as stifling the right of GPs to refer patients.
“Taking away the right to refer means that everyone’s going to be trapped in a doom loop in general practice,” she said.
“And then add on to that the unlimited consultations for routine issues and unlimited urgent clinical requests.
“You can see how the chess moves are being played to try and create checkmate for general practice.”
After 99% of GPs voted to reject the government’s contract earlier this month, though, it appears the NHS has begun to backtrack.
In a letter to practices and primary care networks, NHS England national director for primary care and community services Dr Amanda Doyle said the purpose of SPoA was not to use specialist advice as a way to reject or refuse referrals from general practice.
“I know there have been concerns about the terminology used in the recently published neighbourhood health framework, in particular that SPoA can contribute to a diversion rate of at least 25%,” she wrote.
“But is [sic] important to be clear that there is no national target for specialists, trusts or general practice to divert a fixed proportion of referrals away from hospital care.
“The objective is simply to identify the most appropriate next step for each patient, based on specialist assessment and triage at speciality or sub-specialty level.
“The figure quoted relates to an estimate of the potential proportion of patients, including those who are the subject of an A&G enquiry, who could be appropriately assessed and supported by a specialist consultant without a hospital outpatient appointment.
“It is not the proportion of referrals to be sent back to general practice.”
Dr Doyle reiterated that a GP’s “clinical decision to refer remains unchanged” and that “the clinical threshold for a referral remains unchanged”.
Related
According to the British Medical Journal, the BMA GP committee has welcomed NHS England’s “modified approach” – even though it remains in a formal dispute with the government body.
“The letter from NHS England outlines a modified approach to advice and guidance that both reflects and assures the primary concerns of the GP profession: protecting GPs’ right to refer, confirming that there will be no target applied to acute trusts to reduce their referral acceptance rate and, clarifying the responsibilities upon acute trusts moving forwards,” Dr Bramall-Stainer said, as reported in the BMJ.
The advice and guidance saga in the NHS may be particularly informative for Australia’s Department of Health, Disability and Ageing, which is currently considering options to modernise the country’s patchwork referral system.
