The challenge
Advice and Guidance (A&G) services are central to the vision outlined in the NHS Long Term Plan of ‘one click away’ specialist advice and guidance for GPs, linked to the aim of reducing face-to-face outpatient appointments (NHS England & Improvement (NHSE&I), 2019; NHS Digital, 2021; NHS E&I, 2021).
A&G services allow a clinician, who is often, but not exclusively, in primary care, to seek advice from another specialist clinician before or instead of referral. A&G is defined as non-face to face activity delivered by consultant-led services which can be:
- synchronous, for example, a telephone call; or
- asynchronous, enabled electronically through:
- the NHS e-Referral Service (e-RS)
- other IT platforms or dedicated email addresses, where there is agreement from all stakeholders (NHSE&I, 2020).
In response to the COVID-19 pandemic, clinicians were asked to avoid asking patients to attend physical outpatient appointments where there was a clinically appropriate and accessible alternative. Recommended actions included streaming of new outpatient referrals to ensure management in the most appropriate setting, coupled with A&G provision to avoid outpatient referrals where primary care services were able to access specialist advice (NHSE&I Letters 29th April 2020; 31st July 2020).
The evidence base relating to A&G is developing, currently consisting of service evaluations and case studies and there is limited published evidence. The available evidence does provide detail and practical information about benefits and challenges of A&G, however there was limited information upon which to judge methodological quality. There was also limited evidence relating to the implementation of A&G across a range of geographical areas, in non-specialist settings and via e-RS and non-e-RS platforms. Further evidence was needed to consider the impact of the COVID-19 pandemic and associated change in delivery of health and care upon A&G.
NHS England National Elective Care Recovery and Transformation Team approached NECS Research and Evidence in early 2020 with the following aims:
- To understand primary care and commissioner perspectives on advice and guidance (A&G) services used in the NHS, including uptake, outcomes, barriers, and opportunities before and since the COVID-19 pandemic
- To gather evidence, share learning and understanding to support the ongoing development of advice and guidance within the Referral Optimisation agenda.
Our response
The NECS Research and Evidence and Business Intelligence teams were commissioned to undertake analysis and evaluation which focused on understanding the demand side of advice and guidance. This involved:
- Quantitative analysis to investigate A&G usage, identifying A&G pathways and the proportion of requests that generate an outpatient referral/appointment
- Mixed methods evaluation to understand primary care and commissioner perspectives on clinical A&G services used within the NHS in England
- An online survey exploring primary care staff usage and experience of A&G (390 responses achieved)
- In-depth qualitative interviews to explore primary care and commissioner experiences of A&G (34 interviews achieved).
Outcomes
Key findings from NECS in support of primary care staff and decision makers, suggested what an easy-to-use A&G system would look like.
46 recommendations were outlined in the full evaluation report, across the following nine broad areas:
- Service standards and governance
- Systems
- Elective care pathways
- Widening access
- Resourcing
- Staff engagement
- Patient involvement
- Outcome monitoring
- Further evaluation.
Due to the ongoing need for evidence to support the development of A&G, analysis and evaluation results were also presented to key national stakeholder groups, including national steering groups and clinical councils, as they became available.
In September 2021, a full report on the evaluation and a summary slide deck of findings and recommendations were published online.
The team also presented at the Society for Academic Primary Care 50th Annual Scientific Meeting in July 2022 at University of Central Lancashire and presented evidence at NHS England webinars, including Action on Outpatients in November 2021.
Outputs from this work have informed national policymaking, A&G platform development, further evaluation of A&G services and commissioning decisions.
“Thank you so much for sharing the key highlights from the evaluation work. It will really help focus our Action on Outpatients, Referral Optimisation: Making a Difference work. It was very thought provoking, especially when you put the two evaluations together that have been done on this subject!“