When a GP needs a specialist clinician’s input with the care of a patient, they may make a direct referral to that specialist. Another option is to request Advice and Guidance (A&G). A&G is an electronic way for a GP to ask a specialist a clinical question. The response from the specialist may be to advise sending the patient to see the specialist, to try a treatment, or to do a test. A&G was introduced to speed up access to a specialist opinion and cut waiting times for outpatient care. A&G became more important during the COVID-19 pandemic as it meant patients did not automatically need to travel to a hospital. The use of A&G is now encouraged to help the NHS recover from the pandemic. There are few studies though telling us whether A&G has a better or worse effect on patient care than the usual referral system.
As part of a larger programme of work aiming to study the impact of A&G on patients, healthcare workers and the healthcare system, this study will describe how A&G is being used in the NHS. We will use CPRD Aurum to find out how many patients have had A&G requests. We will describe the patterns of A&G use since 2015 and work out whether some patients (for example, older patients, patient with certain illnesses, or patients from particular ethnic or socioeconomic backgrounds) are more likely to have A&G rather than direct referral.
Advice and Guidance (A&G) allows a primary care clinician to seek expert advice from a specialist, usually in an electronic format. Increasingly, rather than making a direct (elective outpatient) referral, clinicians are being encouraged to use A&G to reduce compound pressures on the NHS. Whilst the use of A&G has been identified as a crucial part of managing NHS waiting lists, there is little evidence of its effectiveness in reducing these compound pressures and some clinicians are reluctant to use it. The potential longer-term risks of harm to patients, such as diagnostic delay, have not been considered.
Our programme of work aims to measure the impact of A&G on patients, clinicians, and the healthcare system in terms of quality of care, satisfaction with the process, and service utilisation. Using CPRD Aurum, Ethnicity Record, CCG pseudonyms and patient-level deprivation the objective of this component is to describe use of A&G by evaluating trends in its prevalence and incidence from January 2015, compared to direct referrals, and variation in its use by socio-demographic and clinical characteristics. Joinpoint and segmented regression will be used to explore the impact of COVID-19 and policy changes on frequency of A&G. Descriptive analysis will assess variation in use of A&G and percentage of A&G requests which end up as a referral by age, sex, geographic region, ethnicity, deprivation, and clinical specialty/nature of health condition.
The other components of this multistage mixed-methods programme are analysis of the impact of A&G on waiting times and outcomes using CPRD Aurum and linked data (protocol to be developed), alongside qualitative research which will explore the experience and perspectives of A&G from patients, clinicians, and commissioners. This will help us to work out whether A&G reduces waiting times and access to specialist care as planned, without making quality of patient care worse.
Advice and Guidance requests
Direct referrals to specialties
Claire Burton - Chief Investigator - Keele University
Kayleigh Mason - Corresponding Applicant - Keele University
Alice Faux-Nightingale - Collaborator - Keele University
Christian Mallen - Collaborator - Keele University
Clare Jinks - Collaborator - Keele University
James Bailey - Collaborator - Keele University
John Haines - Collaborator - Not from an Organisation
Kelvin Jordan - Collaborator - Keele University
Lorna Clarson - Collaborator - Keele University
Ram Bajpai - Collaborator - Keele University
Rosie Harrison - Collaborator - Keele University
Samantha Hider - Collaborator - Keele University
Toby Helliwell - Collaborator - Keele University
Victoria Welsh - Collaborator - Keele University
Patient Level Index of Multiple Deprivation;CCG Pseudonyms;CPRD Aurum Ethnicity Record