A study by an integrated care board has found that the NHS's Advice and Guidance system, introduced to reduce unnecessary outpatient referrals by allowing GPs to seek digital input from hospital specialists, is producing mixed results and in a significant number of cases making the elective care backlog worse rather than better. Senior clinicians have described the system as under-resourced and poorly supported, and have raised concerns that it is adding an unplanned layer of administrative work without the staffing or infrastructure required to manage it.

The Advice and Guidance model was designed around a straightforward principle. Rather than referring a patient directly to an outpatient clinic, a GP could submit a query to a hospital specialist digitally, receive guidance on management, and in many cases avoid a face-to-face appointment altogether. The intended effect was a reduction in outpatient demand, shorter waiting times, and more appropriate use of specialist clinical time. The ICB study suggests that in practice the system is not consistently delivering any of those outcomes.

The primary complaint from consultants is workload. Reviewing and responding to Advice and Guidance requests requires senior clinical time that has not been formally allocated or funded as part of the system's rollout. In most settings, consultants are absorbing the additional queries alongside their existing clinical and administrative responsibilities. The volume of requests has grown as the system has been more widely adopted, and the time required to provide a considered response to each one is not trivial, particularly where the information submitted by the referring GP is incomplete or where the clinical picture requires clarification before useful guidance can be given.

That last point has generated its own friction. Consultants have reported that the quality of submissions varies considerably, and that a proportion of queries require multiple exchanges before the specialist has sufficient information to respond usefully. Each exchange consumes time on both sides. Where the back-and-forth extends over several days, the total time invested in the interaction may exceed what a straightforward outpatient appointment would have required, while the patient remains without a clinical plan throughout.

The consequence that most directly undermines the system's purpose is that Advice and Guidance frequently delays rather than prevents an outpatient referral. Where a consultant reviews a query and concludes that the patient does need to be seen in clinic, the patient is added to the waiting list at the point that conclusion is reached, having already waited for the query to be submitted, reviewed, and responded to. The appointment that the system was intended to avoid has not been avoided; it has been deferred, with administrative delay added to the front of the waiting time. For the patient, the pathway is longer. For the waiting list, the effect is neutral at best.

The clinical risk embedded in that delay is not hypothetical. A system in which queries are submitted and sit in a digital queue before being reviewed creates a category of patients who are neither on a formal waiting list nor actively managed by a specialist. Where the condition involved carries time-sensitive clinical risk, the additional layer of communication introduces a window during which deterioration can occur without triggering the escalation that a formal referral pathway would provide. The ICB study identifies this as a concern that has not been adequately addressed in the system's design or governance.

The relationship between primary and secondary care has been placed under additional strain by the rollout. GPs have been asked to use Advice and Guidance as a prerequisite for direct referral in a growing number of specialties, while consultants have received no corresponding reduction in their existing workload to accommodate the new function. The result is a system in which both sides feel the burden has been transferred to them without the resources to manage it, and in which neither the GP nor the specialist has a clear account of who is responsible for the patient during the period the query is being processed.

The ICB's conclusion is that the system cannot function as intended without dedicated administrative support and investment in the digital infrastructure through which queries are submitted and tracked. Without those inputs, Advice and Guidance is not a filter that reduces demand on secondary care. It is an additional process that consumes clinical time on both sides of the primary-secondary boundary while producing outcomes for patients that are slower than the referral pathway it was intended to replace. The government's 10-year health plan places digital triage at the centre of its approach to managing elective demand. The ICB findings suggest that the preconditions for that approach to work have not yet been established.

‍