Guidance

Introduction

Advice and guidance is promoted by NHS England with the aim of relieving pressure on secondary care services and reducing unnecessary referrals by enabling primary care clinicians to communicate with secondary care services.

This is a direct clinician to clinician discussion that doesn’t involve the patient. It can be defined further as synchronous (e.g. a telephone call) or asynchronous (e.g. via NHS e-referral services, an email address or other agreed IT platform).

We receive a number of questions from practices about this service so have created this guidance which contains our design principles for Advice and Guidance and a frequently asked questions section.

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Wessex LMCs Design Principles for Advice and Guidance

  • Advice and Guidance cannot be mandated.
  • It therefore should be encouraged by designing a system that works for General Practice and is
    • Responsive in a swift timeframe
    • Aims to give advice for that point in time, avoiding suggesting repeated steps where a referral would be more appropriate.
    • Does not seek to transfer usual secondary care workload to General Practice (without a shift in resource).
  • IT functionality should be developed such as the ability to create a referral from an Advice and Guidance request without General Practice needing to take additional action.
  • Advice and guidance systems cannot be mandated as a “GP communication method” to hospital departments.

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Frequently Asked Questions

Can the use of advice and guidance be mandated? Can it be mandated instead of a referral?

No.

This is covered in the NHS Standard Contract which outlines how secondary care providers must keep open eRS referral routes.

03-nhs-standard-contract-fl-scs-2324.pdf (england.nhs.uk)

C6 Choice and Referral

  • 6.1 The Parties must comply with their respective obligations under NHS e-Referral Guidance and Guidance issued by the Department of Health and Social Care and NHS England regarding patients’ rights to choice of provider and/or Consultant or Healthcare Professional, including the NHS Choice Framework. All except AM, ELC, MHSS, PT
  • 6.2 The Provider must describe and publish all acute GP Referred Services in the NHS e-Referral Service through a Directory of Service, offering choice of any clinically appropriate team led by a named Consultant or Healthcare Professional as applicable. In relation to all such GP Referred Services:
  • 6.2.1 the Provider must ensure that all such Services are able to receive Referrals through the NHS e-Referral Service;

This is also a recommendation from the RCGP

To deny the ability of a GP to make a referral would also create a system that would not allow doctors to discharge their responsibilities under Good Medical Practice with the GMC.

In Good medical practice1 we say:

  • You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
  • refer a patient to another practitioner when this serves the patient’s needs

This is underpinned by the NHS constitution that affords patients choice and the above hospital contract which is a legal duty on hospitals to allow patient choice.

Informed choice; Your rights

You have the right to make choices about the services commissioned by NHS bodies and to information to support these choices. The options available to you will develop over time and depend on your individual needs. Details are set out in the Handbook to the NHS Constitution.

And also the guidance from NHSE about the legal rights of patients to choice.

Accepting referrals

Providers who have an NHS Standard Contract with any ICB or NHS England for the service a patient requires must accept all clinically appropriate referrals for that service where legal rights to choice apply. This includes referrals made by primary care clinicians of patients whose responsible commissioner is not a signatory to the NHS Standard Contract which the provider holds but who would instead operate on an NCA basis, as described above.

Once a provider has accepted a referral the patient can expect to be treated by that provider for their entire episode of care, until discharged back to the GP, unless their diagnosis changes significantly or there are other clinical reasons for not doing so.

Should the LMC be consulted on local changes to the Advice and Guidance system in each Integrated Care System?

Yes.

This is covered in the guidance below.

Joint guidance on the use of the NHS e-Referral Service 2018 – NHS Digital

  1. Advice and Guidance (A&G)

Although not strictly part of the core referral and booking functionality, e-RS Advice and Guidance (A&G) is a useful tool in helping GPs to understand the best treatment options for their patients. Referrers can seek clinical advice from colleagues to help enhance their knowledge of how to manage a problem, diagnose a condition, decide whether a referral or follow-up is needed, or whether other, more suitable, management options may be available in alternative care settings. Unlike a referral into a triage service, a request for advice and guidance requires the referrer to act based on the response, which may include the suggestion to refer into a bookable service.

The A&G feature now allows a multi-way conversation to take place between GPs and Consultants that can help strengthen professional relationships, share knowledge and promote important clinician-to-clinician dialogue around patient care. 

Business rules around the use of A&G, including any payments for processing A&G requests, should be agreed as part of local implementation plans in collaboration with LMCs. 

Should General Practice be paid to use Advice and Guidance?

We believe that there should be financial resource and recognition directed to primary care for the use of advice and guidance. This can represent additional workload and risk holding for general practice.

Advice and guidance should not replace a specialist outpatient assessment where this is clearly more appropriate. It should also not result in the transfer of complex investigation and management plans where these would normally be undertaken in secondary care and sit outside of ‘normal’ GP competence.

We are aware of three Integrated Care Systems in England that have some form of payment to General Practice for the use of Advice and Guidance. We know of a local example in the South West of England where we have seen the Locally Enhanced Service specification that outlines this.

Advice and guidance can be considered part of the “left shift of care” and take some workload out of secondary care and into primary care. This needs to be resourced appropriately and this would include payment for the use of advice and guidance to practices.

When activity moves, resource needs to move with it.

Our Integrated Care System promotes a particular IT Platform, can we instead use eRS Advice and Guidance if we prefer?

Yes.

This is covered in the standard NHS contract. The clauses below show that must keep open eRS advice and guidance routes and shows how they are paid to do this.

03-nhs-standard-contract-fl-scs-2324.pdf (england.nhs.uk)

  • 6.2.3 the Provider must offer clinical advice and guidance to GPs and other primary care Referrers:
  • 6.2.3.1 on potential Referrals, through the NHS e-Referral Service; and/or
  • 6.2.3.2 on potential Referrals and on the care of Service Users generally, as otherwise set out in the Service Specifications, whether this leads to a Referral being made or not. The price payable by each Commissioner for such advice and guidance will be either:
  • 6.2.3.2.1 deemed to be included in the Fixed Payment set out in Schedule 3A (Aligned Payment and Incentive Rules), or 
  • 6.2.3.2.2 the Local Price as set out in Schedule 3C (Local Prices), as appropriate;

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Last Reviewed Date
19/03/2024