Cath Dixon
Welcome to the Transforming Primary Care Podcast.

My name’s Cath Dixon. I’m a former GP and I work as Associate Medical Director at Harrogate Foundation Trust and at the interface between primary and secondary care.

In this Series 4 episode, we’re discussing the advice and guidance scheme, which allows GPs to contact hospital specialists electronically for expert clinical advice about patients. Across England, 99% of GP practices are registered for the advice and guidance scheme, which forms part of the 10-year plan for health and it’s three big shifts. In April 2025, more than 43,000 specialist advice requests were processed in the North East and Yorkshire and there were nearly 24,000 redirections to appropriate treatments, the highest across all regions in England.

This was an 8% increase in the number of requests processed the year before in April 2024. So how is this scheme helping prevent patients joining hospital waiting lists unnecessarily? And enabling them to be redirected to appropriate treatment in the community? Joining me today to discuss the scheme’s benefits to clinicians and patients are:

• Dr. Helen Horton, GP and clinical lead at North East and North Cumbria ICB (or Integrated Care Board).
• Dr. Graham Syers, GP partner, Alnwick Medical Group and also clinical lead at North East and North Cumbria ICB.
• Dr. Matt Warren, Consultant Gastroenterologist at Northumbria Healthcare NHS Foundation Trust and NHS England Clinical Advisor on the Elective Recovery Programme.
• Dr. Nina Sloan, clinical lead for the primary and secondary interface, York and Scarborough and a GP at York Medical Group.
• Dr. Veerinder Jandu, GP partner at the Street Lane Practice Leeds and cancer lead for West Yorkshire ICB. Welcome everyone.

So we’re going to start off with the questions. What are the benefits of advice and guidance to patients, practice and the wider system? We’ve seen the recent press releases and updates in the media, just how is advice and guidance helping patients to avoid hospital referrals? I’m going to come to you first, Matt, as you and your colleague Richard were featured in some coverage around the scheme.

Matt Warren
Yeah, thanks very much, Cath. So, to me this is not so much about avoiding hospital appointments, but this is about getting patients to the treatment that they need as quickly as possible. So I deal with gastroenterology, which is bowel and liver conditions. Often really symptomatic patients really suffer with the problems that they’re waiting to see us for, and we felt a while ago that the waits, the length of time that patients were waiting to see us was too long. We felt that patients were suffering unnecessarily with these symptoms.

We felt that they were having to go to see their GPs, this was adding to our GP colleagues’ workload and often patients are trying to seek healthcare interventions in any way they could, which may take them through NHS 111 or even to the emergency department.

So it wasn’t really a kind of service that we felt particularly proud of and we felt that getting patients to treatment more quickly really we felt would benefit obviously them, and that’s the most important thing, but also would benefit us, would benefit primary care, would benefit ED and advice and guidance has just been a mechanism to try and improve dialogue between primary and secondary care to get those patients treated more quickly and more effectively. And that’s really about trying to support primary care colleagues to manage patients closer to home in the community where that’s safe and reasonable and effective. And also to create the capacity for us to see patients who need to be seen in hospital to see them much more quickly.

And we set ourselves really a target of reducing elective waiting times or gastroenterology down to about four weeks. It had been four to six months really before we got started, but that’s too long to wait. So, advice and guidance in and of itself is a tool to allow a discussion and I know there’s a lot of coverage in the press, in the GP media and there’s a lot of sort of feeling and emotion around advice and guidance. But fundamentally to me it’s about patients and it’s about getting them treated as quickly as we as we possibly can. And maybe that avoids a hospital appointment, maybe that results in one, but we can do it more quickly.

Cath Dixon
Thank you, Matt. Really helpful insight from an acute trust. Helen, perhaps I can bring you in as a GP to bring your view.

Helen Horton
Yeah. So I agree with a lot of what Matt has said. We’ve had a very robust advice and guidance system in in the area that I work in North Cumbria for about 8-9 years now and it was set up not as a system to avoid referrals, which I think as Matt said is often quoted in certain sources, but actually about supporting clinical decision making, to use the phrase that’s possibly slightly overused. Right place, right care, right time, right person and it’s a recognition of the fact that general practice over the recent years has got increasingly complex and work that used to not sit within general practice is now sitting very firmly within general practice.

We have an ageing population, we have multi-morbidity, so that means people are living longer with lots of conditions. So general practice in itself is becoming much more complicated and complex. So advice and guidance is really useful to help support the GP with that increasing complexity, which may sometimes mean a referral but may sometimes mean tests or may sometimes mean just advice, but it’s about helping support the GP rather than trying to avoid a referral. And the other thing that’s really key and core – it’s about education and it’s about relationships.

So having advice and guidance, with the digital ways that we use it now, is a bit like picking up the phone and having a chat with your secondary care colleague, but it’s a way that it’s recordable and it’s easier to use and less pressured on time, but it does help those connections between primary and secondary care colleagues in an increasingly fragmented health service. And the other thing, it’s about education. If we if we set advice and guidance up correctly, then every advice and guidance is an educational opportunity for that GP or even for that secondary care colleague who’s being asked that question, because that’s what’s being seen in general practice.

So every conversation, every advice and guidance interaction has the ability to educate the colleagues working together to help develop and improve quality. So I think my feeling is that it benefits the health service because it improves education. It improves relationships and it allows patients to be treated properly in the right place at the right time by the right person.

Cath Dixon
Thank you, Helen. Education is always such a fundamental thing for all of us in medicine. So really important point. Graham, perhaps you could bring us your insight.

Graham Syers
Thanks, Cath. Yes, focusing on the benefits to the patients, I think it enhances or it can enhance the relationship that you have with your patients by having an extra option to share. So there’s something about the trust and your relationship, and it’s about acknowledging that there may be a dilemma that you may need to get some extra help with, but it’s not to that degree of having to wait for a waiting time and a waiting list. So I think what advice and guidance has done in our area, it gave us a mechanism to improve the relationship between us and our local consultants.

Because it gave us something to think about, about how we interacted with each other and it allowed us to set up some rules of engagement, if you like. And in the process of doing that, we were able to discuss what would be the advantages for practitioners in primary care, what would be the advantages for the consultant side of things, what were the advantages for the patients and then where were the barriers? And if we had that open conversation, I think it has given us an extra tool that can be useful. I’m not going to say it was plain sailing, but I’m focusing on the positives at the minute.

Cath Dixon
That’s really helpful, Graham. Thank you. Veerinder, would you like to come in there?

Veerinder Jandu
I think they’ve all been really helpful points so far and I think the key element for this and for myself as a GP and even looking from clinical lead perspectives is that actually it’s all about the patient journey and improving that and I think if there’s a small change that can be made on that patient journey that we can improve, make a little bit more seamless actually, advice and guidance is one of those routes to do it.

I think there’s still few issues to iron out and I think every area across the country is working on that which is really helpful and I think that helps in that that interface discussion. Really interesting to hear you say, Graham, that actually it’s helped you iron out a few issues and work through some ground rules between everybody, because prior to this there weren’t as many. So it’s really helpful for that.

Cath Dixon
Thank you, Veerinder. It’s really helpful to hear of opinion in a different area in Yorkshire in Leeds there. You mentioned the interface, and our second question is, is how do you feel the advice and guidance work is improving the interface between primary and secondary care?

And Graham, you mentioned some rules of engagement as it were. And I know Nina, that’s something you’ve been working on in York as well. Is that something you could tell us a little bit about now? Thank you.

Nina Sloan
Yeah, of course. Thanks, Cath. As a lot of you have already mentioned that communication is key here – advice and guidance gives a really good opportunity to improve those communication lines between primary and secondary care. Within our interface group in York and Scarborough we’re currently developing a quick guide on advice and guidance. So this is – we’ve been in our group discussing what can be done to improve how this advice and guidance is sought and responded to.

So how can we ensure the best possible quality of the advice and guidance requests that are sent through, how can we ensure that advice and guidance is the most appropriate way, appropriate method to be sent through to secondary care and then good practice in how those responses can be most beneficial to be sent back to primary care.

For example, you said Helen about it being an education and an opportunity for education. So what information it’s really helpful to include in those responses to primary care, how detailed, how much, some suggestions on what things to make sure you include in those responses as well as the quality from primary care, making sure that the appropriate information is included so that that the secondary care consultant can respond with appropriate information for that particular patient and you know there is fewer bounce back conversations.

So all the information is there and the most appropriate, appropriate information can be provided and that’s been really well received. We’ve had some really good discussions within our interface group about that. So it’s still in progress, but hopefully it’s coming soon.

Cath Dixon
Nina, that’s really interesting. Thank you very much. Matt, what’s your experience about that interface between primary and secondary care as an acute trust consultant within our group here?

Matt Warren
I mean, I think what Nina’s described there is absolutely fantastic and drawing up those kind of codes of conduct, if you like, are absolutely key because I think we’ve all got to be honest that that because of how busy everybody is, how the NHS has become structured, it does feel that primary and secondary care can see themselves as two very different camps, can’t they? It can be an ‘us and them’ kind of situation. And there is a kind of no man’s land, if I can use that term, that’s developed between primary and secondary care.

It’s nobody’s fault. That’s just how it is, but it’s not to the advantage of the patients, and it’s certainly not to our advantage as a service, but it’s when we start to sort of have a dialogue across that gap, it can be a bit like using social media. It’s all too easy to write flippant comments. And you know, we’re trying to emphasise the positives of advice and guidance here, but I’m sure we’ve all seen some referrals that perhaps didn’t have everything we would have wanted and that rather than build relationships, that can destroy relationships very, very quickly. It can destroy trust.

So I think what Nina’s saying, you know, maybe if you weren’t familiar with this world, you might think, well, why on earth do primary and secondary care consultants have to learn how to be polite to each other, but actually there’s no harm in it.

And the little sort of niceties, the dialogue, the thanks for the referral, the positive affirmation around education – “you’ve done a really good work up on this and I really appreciate it”, you know, might seem a bit cheesy, but to me those things go in a long way. And I always kind of imagine that primary care, maybe my colleagues on the call will correct me, but I always imagine that you’re reading these A&G replies at the end of a kind of 50-patient clinic or something like that and you’re probably pretty frazzled.

And if you’re anything like me, you’re primed to take offence at the earliest opportunity. So we’ve got to be uber-careful that we don’t give you anything to be offended by, if that makes sense, you know, and I just think that that the professional courtesy goes such a long way in building relationships.

Cath Dixon
I couldn’t agree more Matt and I think it’s really tricky when we’re all so busy at the coalface in primary and secondary care to remember that we’re team NHS and we’re actually all on the same side trying to do our best for patients and education and working together is part of that, but I really value your insight there. Helen, perhaps you could add something to that as well?

Helen Horton
Yeah. So I absolutely agree with that sort of rules of engagement between when you’re having that individual dialogue, we all get tired, we all get stressed. And I think that that’s that sometimes is exacerbated by use of digital approaches rather than some things you would say in a letter or in an ‘advice and guidance digital’ is not necessarily something you would say on the phone. So I think that’s really, really important.

But I think in terms of the interface, you’ve also got to look at how advice and guidance is set up because if you just think, oh, you can plonk advice and guidance in and it’ll work that in itself can impact the interface between primary and secondary care, because if it’s not put in thoughtfully, then it’s seen as an extra job, a chore, and it doesn’t get the same engagement.

For example, primary care responsibilities – locally we always encourage our clinicians who are in primary care if you’re a trainee for example, go and have a chat with your supervisor before you put the advice and guidance in, because actually they might know the answer or the answer might be there available for you. So don’t waste secondary care colleagues time asking a question that might be easily answered.

From a secondary care perspective, when we set it up, you have to put time in their job plans. You can’t expect this to be an add-on because it potentially, I mean if you look at – and we’re probably going to talk about it later-, but if you look at the figures, this is depending on which department you’re in, can be a huge amount of additional work.

Well, it’s not additional work, it’s work that may or may not end up in a referral or may have been a referral before, but it is still work that needs to be done so it needs to be reflected in people’s job plans so they can they can build it and then they get less frustrated and then you have more time to give them more reasoned and a more thoughtful and a more educational answer. And the other thing is if you’re setting it up effectively, it’s how does it link with other services to again support both primary and secondary care at the interface.

So the questions that have been asked are the right questions that really, really get to the heart of the problem and really support the patient. So we link ours up with the system we’ve got currently which is called health pathways. So there is a tagline on our advice and guidance saying please consider health pathways.

Our secondary care colleagues will say, yeah, here’s the answer, but have you thought about health pathways? So you’re kind of linking it in with your local clinical guidelines work as well as you know it being that dialogue and all of that sort of thing helps support and make things slide easily against each other at the interface. And if you don’t think about the wider part, that’s when it gets jagged and it doesn’t work. 

Cath Dixon
Thank you, Helen. And I’ve blatantly used that in Harrogate by asking consultant colleagues to come and speak at GP training sessions. And usually each session is just based on your frequently asked questions for advice and guidance. And then we’ve published those afterwards. We’ve recorded those sessions and actually made them available on our SharePoint locally. So that’s been helpful for our colleagues. Graham, perhaps I can bring you in before Veerinder?

Graham Syers
It was just a final point really on clinical interface groups. I think we probably come from a place on this call where we have pretty functional clinical interface groups for whatever reason. And I think it’s important to recognise that the relationship between primary care and secondary care is at very different stages of maturity in various different parts of the country. And therefore what a clinical interface group is capable of doing at any moment in time will vary.

And I think sometimes we are asked to do certain things in certain forums and what might work well in one place may not work well in another and is always a case for I think reflecting on what is it that we’re trying to achieve with the clinical interface groups and what’s the leadership of those groups and who’s helping that process? Because at the minute I have an anxiety that many things are being asked of clinical interface groups and advice and guidance is one part of that relationship between the two.

And there are other forums where advice and guidance can be discussed, such as educational forums that you’ve mentioned and other places. So we’ve just got to think about that. We aren’t talking about the LMC today, but in some areas, clinical interface groups can be complicated by other relationships around LMCs and it’s how the system responds to all of that and we can’t just focus on one particular area.

Helen Horton
Just to come in on that, totally and utterly agree with that Graham, and we’ve had a separate advice and guidance steering group as such in North Cumbria for the last eight years to just focus on advice and guidance because the interface groups are overloaded with interface stuff at the minute. So to do it effectively, it needs resource and it needs proper focus.

Cath Dixon
Absolutely. Thank you, Helen, and thank you, Graham. Veerinder, perhaps you could give us your view from Leeds, which is a different area of the country with a different interface outlook.

Veerinder Jandu
Yeah. So I think there’s some really, really interesting points in that and I’ve made a few notes if people don’t mind for this, but I really liked what was mentioned earlier by Matthew about actually respecting one another’s professional boundaries and I think this is quite a useful area where we expect to make a high quality referral, how we can build on that using advice and guidance.

I think once you’ve had some advice most GPs will learn from that for the next time they’re sending one in – if they feel actually “I need to prepare a test beforehand” or they could do with a bit more information and I think that conversation, it gets facilitated by advice and guidance to then allow secondary care trusts to really pass on useful information that’s within primary care’s boundaries.

So I know that there are worries sort of across the country about actually, is this an appropriate thing to request back via advice and guidance? But continuing to engage with it can only help to improve the system. So that’s really useful. And I think within Leeds we’re doing lots of things within an interface setting and I think there’s lots of lessons to be learned across all the various specialties and looking at actually what are those professional boundaries, what are those quality referrals that we need to be making?

Cath Dixon
Thank you. That’s so helpful. And I think that leads us on really to – has the scheme in in Cumbria been straightforward to implement and Northumbria, are there still bumps in the road and what advice would you give to professional peers on making the most of the scheme? And those who are sort of only just tentatively establishing these groups, Matt, perhaps I can bring you in on that one.

Matthew Warren
Yeah, I’m going to jump in with the secondary care bit first. There are absolutely bumps in the road and you know, nobody could ever say otherwise, but there are bumps in the road with the status quo as well, if that makes sense. And I think, you know, perhaps we feel don’t we that the current system is not really working as best as it could for our patients.

And you know, I personally feel that the long waiting times that we have impact the patients, impact GPs, it’s professionally very unsatisfying to do a clinic where you spend half your time apologising to the patient for how long they’ve had to wait to see you and the other half saying, well, actually you’re in the wrong clinic because I can’t take your gallbladder out. Well, I’d have a go, but you wouldn’t thank me!

So I think there’s a lot of professional satisfaction in in having that dialogue between primary and secondary care and offering patients a better service, but it’s a big change in how we do things and I’m very sympathetic to GPs who absolutely perceive that this will be holding more work in primary care that traditionally, you know, it is felt we would have done and that’s probably true.

So I think we’ve had to overcome a lot of understandable GP concern. We’ve had to overcome a lot of trust concerns about income streams and funding and resource.We’ve had to select our team. So I think it’s been incredibly, you know, personally it’s been incredibly rewarding. We’ve got where we wanted to get to roughly in terms of speed of access to patients.

But it’s a process that’s required a lot of work with colleagues like Graham and also constantly refreshing. You know, you’ve got to be constantly checking what’s going well and what’s not. And I think to other teams around the country from a secondary care perspective, I totally agree with what Helen was saying. You’ve got to back your consultant team. This is very skilled and resource intensive work. It’s to be done instead of not as well as – pick your clinical champions, get them out there into primary care and start building those relationships because we’re all going to drop the ball at times about this.

And someone said to me once, I can’t remember who said, you know, if you know that somebody’s a good person, you’ll forgive them dropping the ball every so often. If you have no idea who they are, you’re very quick to make a judgment about them when they drop the ball. So that, medicines built on relationships, isn’t it? And it’s hard to measure and hard to build but just get out there and get started. For us it’s been so rewarding to do.

Cath Dixon
Absolutely. In my experience, absolutely reflects yours, Matt, in terms of building those relationships, consultants in different departments having varying degrees of affinity to using advice and guidance and the sort of blows that can happen between GPs and consultants about clinical governance and whose responsibility those test results are when they’re outside my clinical expertise. Helen, can I bring you in?

Helen Horton
Yeah. So obviously we’ve had advice and guidance set up for quite a while. We developed it not for any reason to avoid referrals, but actually to help support clinicians. And we developed it with a small project team which included somebody from the ICB to help support who’s phenomenal and primary and secondary care clinicians and somebody from the trust to do the project management on that side.

So it’s a small focus team but their focus was just advice and guidance and there was a long run up in terms of engagement with primary and secondary care clinicians, thinking about the technicalities and the practicalities before you put it in and also the reason why we were putting it in. So that was very clearly given as the message to clinicians so they were on board with it. And then as with any project, it was going with your departments that were more robust or were more on board to start off and then sort of picking up the departments that were a bit less keen as you as you move on.

And actually what we got to a point where we found we actually have had departments coming saying can I go onto advice and guidance please, you know, because of the benefits that you see and as you say it’s that continual refresh and review. Are we meeting the standards we’ve set? Have we got the right services on? Do we need more of the services on?

So it’s that continual review and refresh and I mean we’ve been, you know I was just looking at the figures earlier, we’ve got predicted 16,000 conversations this year in North Cumbria which is up from 15,200 last year and I think the other thing is as well as from a secondary care perspective giving the consultants time and parameters to work within, but also the advent of the advice and guidance enhanced service has been very, very helpful locally because this is work we were already doing but It is a recognition that it is more work on general practice because in 30% of our cases we’re avoiding a referral.

So the work that would have gone to the hospital is staying with us. So that recognition centrally of that work that is being kept in primary care that would otherwise potentially underpin the referral was very welcome after 7-8 years of us doing it for the good of the patient and the education of the clinicians. But you need a focus, you need a team and you need that constant engagement. You need a really clear vision of why you’re doing it and what it’s beneficial for. And that’s where it’s about quality, it’s about education, it’s about support. It’s not about avoiding referrals.

Cath Dixon
Thank you. Graham. I’m going to bring you in and I’d be really grateful for your thoughts as well on how this is done electronically, whether it’s done by ERS in your area or as it is in ours or how that’s done.

Graham Syers
Thanks. Yes, certainly on the electronic side of things, as a GP I like to try and stay away from as much of the admin as I can. And therefore when we knew we were asking for advice and guidance, it was very clear to our admin staff that was what we were after. With ERS, it seems subtly different.

We’ve been invited to take part in a pilot, which I will be looking forward to. We have slightly different trusts using different systems, which can be confusing. I think clarity about “am I asking for advice and guidance or am I giving this information and the hospital consultant will decide”, feels like I have slightly less control and I can be slightly less confident to tell the patient what the outcome is likely to be.

So that’s one of my anxieties about the ERS system. I can imagine the 10-year plan and us all using marvellous electronic ways of communicating better with each other, but if things start coming direct to me in an inbox and it’s not really monitored in the practice what’s going on. I can see slight holes in that. Where it sounds great to communicate directly to a doctor, I think sometimes we need safety nets in place where things do get monitored and come through admin just in case there’s absences or something’s gone missing.

So there’s a new system to come and I’m really open to finding out how that will work, but I don’t want to lose any of the advantages of the A and G. On the other hand, I know we all have habits and sometimes we have to accept change. On one other slight thing, I’ve been monitoring with interest the change in behaviours since the DES has come in like Helen has, we were a relatively early adopter. It was welcomed that there was a DES, but I have seen some changes in behaviours, I think probably as a result of a contractual element to it.

And I’m not sure where that fits in terms of us as system leaders in ICBs. If we see variation in advice and guidance, should that be part of our quality assurance system or is it part of our contractual system? And I think there’s still some elements of that that we need to be thinking about.

Cath Dixon
Thank you, Graham. And indeed that sort of segues us forward. Helen, would you like to give us your insight there? I realise you don’t use ERS, the electronic referral service in your area.

Helen Horton
Yeah, yeah. So I suppose it was two points. Just to come back to Graham’s point about the figures, so 2023/24, we had a 3% increase. So we do see a year on year increase in advice and guidance, you know, as people just use it more and more. So it was 3% in 2023/24 and it’s looking like it’ll be about 5% in 25/26.

So there has been a slight change in behaviour, but nothing that I would be concerned about in terms of people gaming the system or using, you know, using it inappropriately. For me it’s that that’s a natural trajectory. So I’m quite pleased that the clinicians locally have not made any significant behavioural changes with the enhanced service coming along. We use a different system from Morecambe Bay which is embedded within our GP records.

So it’s initiated by the GP from the GP record and there’s a whole background system and then the response comes back to that GP. So it’s very much the responsibility of the GP requesting it, but the benefit of it is – it saves it into the GP record very clearly just as a document. So it’s a really clear and obvious conversation that the patients can see as well and it’s a conversational approach, you can have multiple to and fro’s about the same advice and guidance which is really good.

It does lack at present the ability to make referrals from that system into the ERS and I know we are being moved towards ERS. I will look at the new developments for ERS with interest, but hopefully it will maintain the flexibility, the GP initiation and the ability for that record to be very visible for the advice and guidance responses that we’ve been used to for the last for the last 8 years because it’s a very good system that we have.

Cath Dixon
Thank you, Helen. And just clarifying for those listening that when we’ve been talking about a DES, that’s directed enhanced service, the nationally commissioned service that GPs can opt into, which means that if GPs send advice and guidance, which is so much better for patients, and especially in our rural area, can stop them travelling miles for an inappropriate consultation, the GPs are paid for that. Matt, have you seen that create a difference in your workload at all?

Matthew Warren
The enhanced service? Probably not because I think, I think we, as Graham said, we’ve been doing it for quite a long time and I think our GPs are very familiar with it. So probably not and I think one of the things I know that secondary care was worried about was that we would be flooded with spurious referrals because there was GPs on the group would have to comment on that. I never felt that the £20 was enough money to make it worth your time to send a spurious referral.

So I kind of assumed that wasn’t going to happen, but I know that has been a concern. I was quite keen to hear from sort of GPs in the different region, maybe Nina and Veerinder, one of the things we really hoped that that A&G would do would be to encourage GPs to discuss with us cases that never kind of met that threshold for a formal referral, if that makes sense. So I don’t know if you’ve any experience of that? Graham on the call, you know he’s always crying for help when he doesn’t know what to do, no, Graham, I’m teasing you!

But we definitely felt that, you know, there may be things that you were seeing that you were just not quite sure about that we could really quickly steer you and say no, don’t worry about that or do this. Is that something that you get through your A&G or is that kind of a benefit that something will have never, never been a referral ever anyway, but can still be helpful to you and the patients?

Cath Dixon
Veerinder, do you want to answer that for Matt?

Veerinder Jandu
Yeah. So I think we are seeing some useful implementations for it that possibly wouldn’t have been a referral, but might have been a phone call I guess for it, which would take you a lot longer than an advice in a different, less formalised way. So potentially there is a shift of people looking for what’s really a more modern and digital way of getting this advice and guidance rather than having to pick up the phone and contact a consultant via a lengthy hospital phone line.

So I think there’s that that shift in it. I think what we’ve seen within Leeds is probably that actually the DES hasn’t influenced more people sending advice and guidance, but actually it’s a useful way of capturing how much was being sent because I think the volume has been there, but it’s just been on potentially unrecognised channels and not necessarily been monitored.

Cath Dixon
Thank you, Veerinder. That’s really helpful. And I certainly know my area, the advice and guidance requests have gone up and I hear about it from the consultants because that’s obviously had a big impact on them. Nina, is there anything you wanted to add in to there?

Nina Sloan
I just wanted to ask Matt a cheeky question, if that’s all right. You talked a lot about the language used in the responses and it sounds like you really carefully consider how you write back for advice and guidance requests, and I was just wondering what your thoughts are about the template responses. Have you been involved in some of the writing of them? I feel like you perhaps have been.

Matthew Warren

The gastro ones, yeah. I think it depends where an organisation is at in the kind of evolution of its advice and guidance service. So I think if you’ve got nothing, then it’s not a bad place to start because it’s, you know, it’s been, it’s gone through patient advocacy groups, it’s got GP co-authorship. It references guidelines. But it’s not where we want anyone to end up.

So I think it gives a framework it, but it’s impersonal. It kind of feels like it works better for advice and guidance than it does advice and refer. So what we do that we didn’t allude to is we run everything through advice and guidance.

Now Graham, that kind of speaks to your point about not knowing what you’re going to get and that’s why we really encourage this sort of, you know, again, another sort of cheesy aphorism that I like is ‘discuss with’, not ‘refer to’. What we would really like is if primary care would say I’m going to discuss you with a gastroenterologist and see what they think. They may want to see you or not, because I totally get that expectation thing is really, really difficult to overcome, isn’t it? I totally get that if you’re a GP and you say, oh, you need to see a gastroenterologist and muggins here says, ‘Oh no, you don’t.’

How does that build your relationship with your patient? It probably doesn’t at all, does it? The patient might think, well, the GP doesn’t know what they’re talking about. So we really wanted to kind of get away from that. You need to see, you know, I will discuss with (it doesn’t always work) Use them if you’ve got nothing better, because they’re okay, but they’re not great. I don’t know, what do you think, Graham?

Graham Syers
We had a discussion going back 2-3 years. Matt with the GPs: Some wanted proformas, some didn’t. The anxiety was the proforma takes away the personal relationship and it makes it much more structured. Some people like that, others don’t. The majority didn’t want it, so we never went round the pre-empted ‘this is the information you must give us’ if it’s permit a gastro. It does lead to sometimes gaps for information in certain circumstances, but it was felt not to go down the proforma route. There’ll be pros and cons.

Cath Dixon
Very much so, Nina.

Nina Sloan
I had wondered if you had a slightly different system within an advice and refer system. In York we’ve got a kind of a hybrid, we’ve got some on a rapid expert input service which is similar I think to your service but using a different computer system and some on an advice and guidance system where the referral advice and guidance run separately.

I try and use this term of I’m going to discuss with secondary care, particularly in those ones where we use the rapid expert input and it goes down really well with patients because I say to them I’m going to get a response in the, you know, within the next week, probably maybe a couple of weeks maximum and I’m going to come back to you. And they are really satisfied with that response because they know that they’re going to get something quickly.

They know they don’t have to wait weeks for that response. And actually where we have the rapid expert input, it works really nicely because I can say I’m not sure whether they need to see you or not. I’m not sure whether it’s a referral, but let me put that question to the consultant and they’re going to come back to me and if they want some tests while you’re waiting, we can organise that.

And it’s a really nice system where you can get that response and you can see whether it’s a referral has been made or it’s been accepted as a referral or they’ve just sent the advice back or they’ve done both. They’ve been accepted the referral, but they’ve said please could you order these blood tests in the meantime or please change the medication in the meantime, but we will see them in clinic. So really, you know, works really well for patients. So I would recommend for anyone thinking about it to use the phrasing that Matt’s talked about. Discussing with the specialist, rather than just saying I’m going to refer.

Matthew Warren
Well, that’s really nice to hear actually because we make quite a lot of assumptions about what we think you think and what we think patients think. So it’s really nice when it works. So the way we run it is that we do everything directly through ERS. We only have A&G and we call it advice and refer and 99% of our GP referrals have authorisation to convert. So we don’t ever send them back for a referral. That feels like an unnecessary burden to you. What’s the point?

So the reason I like it, Graham may correct me here, is that you can return with advice and often the GP would upload that, that reply is then visible to the patient and that horrified me when I first found that out. And now I love it because you can, you can put self-management links in what not. Also if you accept them onto a waiting list and let’s say you’ve got a service that has a nine month wait, you can offer interim management advice.

You know we’re going to see you, it’s going to be about nine months, and in the meantime, you can try this and trusts are supposed to ring their patients who are on a PTL or waiting list every 12 weeks and see if they still need the appointment. And you know, sometimes people get better with the interim treatment that you give. And the other thing we found was quite useful because GPs had fed back to us that they were often referring to us with, I don’t know, heartburn or something.

We would go direct to test because that was quicker and then the patient would be discharged with a normal endoscopy and the GP would be saying, well, but they’ve still got heartburn. And so I think what A&G allows you to do is say I’m going to send them for an endoscopy. Actually, I think it’s going to be normal because they always are, but we’ve got to do the endoscopy for whatever reason. If it’s normal then – XYZ. So it kind of it helps you give a bit of kind of wrap around care and you know we hope that what that means is that you get a patient bundled up a bit more for you.

And from our point of view we’re not seeing patients in clinic who we don’t need to be seeing. So we can see the ones we need to see more quickly and you know we’re at about two to three weeks now for routine gastro. That’s our waiting time. So I guess the other thing I didn’t really come back to was I guess what we hope then is that you’re not having to manage patients waiting nine months on a gastro waiting list because we’re seeing them in three weeks.

The selling point we hope to GPs is that we may ask you to hold some work in primary care that you would traditionally have asked us to do. Nobody can deny that, but in the totality, we hope that we’re supporting you to manage patients – that advice is useful and that saves you some time. And actually you’re not managing patients who are waiting nine months to be seen and constantly chasing their appointments and all that kind of thing. So we are trying to give you work with one hand and take it away with the other. Anyway, that’s my pitch – that’s my elevator pitch.

Cath Dixon
Thank you. I’d like to bring us to think about how advice and guidance will continue to develop to meet the aims of the 10 year plan and the medium term planning framework and how the leaders we have in the call who’ve been doing advice and guidance for many years and those of us who perhaps are trying to establish it going forward, whether we feel that advice and guidance will develop and help us with the 10 year plan. Matt, thank you.

Matthew Warren
So I think, I think for us in secondary care, this is going to be a huge change and it’s going to kind of disrupt the way that consultants think that they practice and that they work. I would say a lot of secondary care clinicians really only see their responsibility to the patient as starting when the patient walks through the door of their clinic room.

And you know, I probably shouldn’t say this sounds very dismissive of secondary care, but we’re plenty busy enough with that. But seeing people on the waiting list as our problem is not really something we’re trained to do. Moreover, we don’t really see public health necessarily as our problem, but I think the INT kind of breaking down the barriers, left shift, whatever you want to call it, we’re going to have to start engaging with those populations, aren’t we? And that’s good.

I think A and G kind of starts to get us thinking outside of the walls of an outpatient department. It starts to get us thinking more into primary care, more into preventative medicine and so I think if we can get the new generation of consultants sort of trained to do A&G, trained to dialogue better with primary care, trained to think outside of the footprint of the hospital. I think we kind of ease ourselves into some of those really fundamental changes that the 10-year plan is going to going to going to bring.

Cath Dixon
Thank you very much, Matt. And that’s definitely the voices that I’m hearing as well from secondary care and the opinions are very much reflected on that, that that the job starts when the patient’s in front of them and advice and guidance changes that and we need to all be supporting each other. I’m conscious that we’ve got a limited amount of time. So Helen, I’m going to bring you in then Veerinder and then Graham after that, Helen.

Helen Horton
I agree with Matt’s thoughts and I think advice and guidance allows to open the door to secondary care clinicians on the complexity the general practice deals with on a daily basis, which is sort of integral in the 10-year plan about how you manage that slightly differently. And the other thing as well as I come back to what I said at the the first question, it helps you provide the right care at the right time in the right situation, because it’s breaking down that artificial barrier of having to go to a big shiny building to have your appointment and then come back out.

So it will help that left shift into the community and out of the hospitals if we use it more and more and it is used about quality of referrals, not deferring referrals. I keep stressing that point because that point for me is absolutely key that we’ve got to get. It’s about quality of referrals and support, not deferring referrals.

Cath Dixon
Thank you, Helen. Veerinder, perhaps I could bring you in there.

Veerinder Jandu
Yeah, I’d echo Helen’s thoughts about that, that quality on referrals. I guess from the 10-year plan, I think the analogue to digital switch is really important here. I think as we see more, more advice and guidance requests coming through having a better, shared healthcare record systems, whichever digital platform that the ICB is choosing for that, I think that just carries so much, so much more weight and improves the quality of advice and guidance that can be solved, rather than entering a back and forth between the dialogue of which medicines have you tried and which ones haven’t we got?

Those small answers may be able to be picked up by better digital transformation. I think once we see that happening, I think there’s a real improvement that we can see in the quality of advice and guidance being received in primary care.

Cath Dixon
Thank you so much, Veerinder and Graham, your thoughts on that please.

Graham Syers
Trying to be brief, but my thoughts are around Matt’s around having a shared responsibility for a population which is out with the bounds of our current organisational boundaries, and the great hope is that Neighbourhood Health will move us in that direction.

Somehow we have to create an environment where we all do have the freedoms to say, yes, this person may become directly my patient in the future, but where can I intervene now that improves that pathway, that journey? It’s all about using our resources as best we can for the patients. So there must be better ways of doing it. And I think we’ve fallen into patterns at the minute, which our system has encouraged, perhaps in the transactional nature of how it works. And if we can move into a slightly different system on that sense, I think the relationships between the practitioners in the different organisations will improve.

Cath Dixon
Thank you, Graham. And I think that sums it up beautifully in the fact that advice and guidance is a system. It’s built on those relationships between primary and secondary care. We need to stand together to work for the integrated neighbourhood teams working for patients in their communities and changing that and using digital to enable that in the future. I’d like to thank my colleagues Matt Warren, Graham Syers, Helen Horton, Nina Sloan and Veerinder Jandu for their thoughts and thank you for all the good work you do looking after those patients.