The Health Services Safety Investigations Body (HSSIB) report identified patient safety risks linked to the roll-out of the services that allow clinicians in general practice to seek specialist advice from secondary care, either before or instead of referring a patient to hospital.

Dr Nick Woodier, senior safety investigator, HSSIB, said: ‘A&G services are making a real difference for patients in many parts of the NHS, and we heard genuine enthusiasm for what they can achieve. But we also heard serious concerns and found evidence of harm where implementation has not been adequately designed or monitored.'

The HSSIB recommended NHS England and the DHSC undertake a rapid evaluation of A&G services with the aim of addressing resource and capacity gaps, workforce training needs, e-RS digital risk management and weaknesses in patient safety incident reporting.

HSSIB also recommended NHS England and DHSC, working with relevant Royal Colleges, commission the development of standardised A&G request and response templates for specialties where these do not currently exist, and support their effective use in practice.

NHSE was forced into a climb down in April after asking GPs to cut hospital referrals by 25%. GPs have, however, continued to report referrals to secondary care being sent back by hospitals.

Reaction 

Director for primary care, community and neighbourhood health at The NHS Alliance, Ruth Rankine, said: ‘The findings in this report underline the importance of getting implementation right and we support ongoing review of its application and effectiveness.

‘The examples of patient harm reinforce the need to identify, monitor and manage patient safety risks.

‘As advice and guidance is extended, it is important that success is judged by patient outcomes, quality of care and clinical benefit, rather than focusing on activity levels or reduced referrals.'

An NHSE spokesperson said: ‘As HSSIB acknowledges, advice and guidance has positively influenced patient care by reducing waiting times and giving people quicker access to specialist advice, but we know more needs to be done to make it work even more effectively.

‘That is why we're giving GPs and hospitals clear guidance and practical tools to help deliver the service safely, consistently, and effectively across the NHS, and have already commissioned an evaluation of its impact which will be published this year.'

Beccy Baird, senior fellow for primary care at The King's Fund, said: ‘Although in this report NHSE and the Department for Health and Social Care state that A&G is never mandated, and instead local GP practices are expected to use A&G prior to or in place of a planned care referral, where clinically appropriate. However, the HSSIB has found clear instances of local pathways where A&G is a compulsory gateway for referrals for some specialisms, creating widespread confusion amongst clinicians and commissioners of NHS services about whether A&G is optional or compulsory.

‘This confusion is made by worse by expectations A&G will reduce referrals by 25%. Whatever the intention, this risks NHSE sending a signal to the system that cutting referrals matters more than getting patients to the right care quickly.'

Royal College of Physicians

The HSSIB report followed data from the Royal College of Physicians (RCP) which revealed a widening gap between the amount of NHS Advice and Guidance work that physicians are being asked to deliver and the time allocated for it in their job plans, with many reporting that they complete this work in the evenings and on weekends.

RCP clinical lead for outpatients Dr Ash Sharma said: ‘These findings show that A&G is still being delivered without the planning or resourcing physicians needs. Already overstretched doctors are essentially working for free to get the right care for their patients. This is unacceptable and unsustainable.'

Dr Munro Stewart, vice president of the Royal College of GPs, said: ‘A&G services have potential to support GPs, specialist colleagues and patients, but they need to be implemented properly. As such, it's important that polls such as this and other feedback from frontline clinicians in both primary and secondary care are taken on board as part of wider evaluation, so that issues can be identified and addressed.'