A secondary consultation system could cut up to 70,000 GP-to-specialist referrals per year in Australia. So why are GPs in the NHS pushing back on a similar program?
The government has finally committed to overhauling referral pathways and fixing increasing non-GP specialist costs.
There are some who see this as a chance to go farther by implementing a formal secondary consultation system where a GP contacts a hospital-based specialist for advice and guidance prior to referring a patient.
Proponents say it could save patients $4 million in out-of-pocket costs and avoid up to 70,000 specialist appointments each year, if done correctly.
That’s a somewhat loaded caveat. The UK’s National Health Service already has a similar program in place, known as Advice & Guidance (A&G).
For reasons which will become clear, A&G is at the centre of the latest spat between GPs and the NHS. That quarrel has now escalated to the point where 99% of the British Medical Association’s GP members voted to reject the UK government’s latest contract.
So where can Australia get it right where the NHS got it wrong?
What’s on the table?
While various models have been suggested in the past, the most recent, comprehensive proposal for a secondary consultation system was proposed by the Grattan Institute in a 2025 paper on improving access to specialist care.
The think-tank proposed a digital, asynchronous system where a GP would ask a question and share relevant patient information with a hospital-based specialist, who would then provide detailed written recommendations on diagnosis and care or advise that a referral is necessary.
GPs would be paid a fixed annual payment of $156 in return for using the system and receive an additional $5 every time they submitted a question.
By the Grattan’s math – which assumes that GPs would use the program about 11 times per year – GPs would earn about $18.50 every time they used the secondary consultation program.
To balance out the other end, public hospitals would receive state government funding to roster extra part-time specialists who would be dedicated to answering the questions received from GPs.
“It might be the lowest hanging fruit in dealing with all of the demand for specialist care that the [current health] system is struggling to meet,” Grattan Institute health program director Peter Breadon told The Medical Republic.
“The basic idea is that GPs can get text-based advice from a non-GP specialist within three days through a secure messaging system, and we based it on a model that was piloted and has now been made permanent in Queensland and also models in North America.
“The evidence [from those models] is really strong that you avoid a lot of unnecessary referrals, you save patients quite a bit of money in out-of-pocket fees and the cost is quite modest.”
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A cautionary tale
On the face of it, this is not dissimilar to the model being pushed by the NHS.
But there is a key difference.
The NHS, in its latest draft GP contract, is planning to force GPs to consult a specialist via A&G before they can refer a patient.
The chair of the British Medical Association’s GP committee, Dr Katie Bramall-Stainer, said that it would turn general practice shifts into “a 12 hour digital triage monkey fest”.
“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.”
Beyond the workload element, there are concerns from some local medical committees that GPs will be held clinically responsible for patients while awaiting advice and that urgent treatment will be delayed.
“We have seen a case in our region in which an urgent cancer referral was converted to an Advice and Guidance response more than once rather than accepted as a referral, and where we believe the diagnosis that followed was delayed,” the Wessex Local Medical Committee said in a statement.
While it’s unlikely that Australia would move down the route of making a secondary consultation system mandatory – for one, the Australian Commonwealth does not contract GPs directly – some of the risks of A&G do translate across.
“We do know that some entities are making statements to the effect that the GP bears the full responsibility for the patient, but we don’t think that’s the case and we don’t think that it should be,” senior medical advisor at medical indemnity firm Avant Dr Patrick Clancy said.
“There should not be attempts to put that back onto the GP. If any sort of doctor is involved in in patient management, then they have responsibility to ensure that they provide a quality and accurate service.”
Dr Clancy, a Brisbane-based GP and sports doctor, also spoke to the risk of an overly prescriptive system.
“What has been proposed seems to be a limited written question and answer system where it might be one question or three questions,” he told TMR.
“And in some cases that will be really good, but it often can’t replace a dynamic conversation between doctors.
“I know myself, there’s plenty of times that I’ve rung up non-GP specialists for advice or thinking about whether they need to see the patient or the things they actually do need to see the patient [for] and see them fairly promptly.
“Then we have that good dynamic conversation, and the specialist might come up with all sorts of things that I haven’t actually considered or haven’t asked the patient, or other things that I should do, and we can sit there and have that discussion.”
How would Australia avoid the risks?
Associate Professor Vikram Palit runs ConsultMed, a digital referral platform that facilitates secondary consults.
He sees the formalisation of advice and guidance as a boon, risk-wise.
“[As consultants,] we provide advice all the time,” the specialist paediatrician told TMR.
“We’re on call, we pick up the phone, people page us, we get emails. The concept of providing quote-unquote ‘free’ advice is not foreign and it’s part of clinical practice.
“But this is secure and there’s governance around it, it’s auditable and you can manage it within your clinics.
“[If it’s a] … GP calling me and me providing advice on the phone, I have no idea … if that advice was taken or what happened to the patient, whereas [a formal secondary consult model] actually captures it.”
Professor Palit also said that Australia could not be directly compared to the UK in terms of health systems.
“In the UK at some of these trusts where there’s so much pressure – what they’re worried about is that if the referral pathway is gone and it’s just A&G, then the GPs may be burdened with quite sick patients who can’t actually enter the hospital system,” he said.
“And that’s actually quite a risk in the NHS, but in Australia I think that risk is a lot less.”
