The Health Services Safety Investigations Body has recommended that a rapid evaluation of NHS advice and guidance services is needed to protect patients. 

NHS advice and guidance services can benefit patients but must be better implemented and more rigorously evaluated to support safe expansion, a report by the Health Services Safety Investigations Body (HSSIB) found.

In an interim report, it identifies patient safety risks linked to how advice and guidance (A&G) services have been implemented across England. These allow clinicians in general practice to seek specialist advice from secondary care, either before or instead of referring a patient to hospital.

“A&G services are making a real difference for patients in many parts of the NHS, and we heard genuine enthusiasm for what they can achieve. But we also heard serious concerns, and found evidence of harm where implementation has not been adequately designed or monitored,” said senior safety investigator Nick Woodier. 

It found that poorly designed or inadequately monitored pathways have contributed to physical harm, delayed and missed diagnoses, and in some cases to delays in cancer care.

“We need to be clear that the success of A&G should not be measured simply by the number of referrals avoided or the volume of A&G requests processed. The important question is whether it is helping clinicians make better, safer and more appropriate decisions for individual patients. A reduction in referral numbers is not a success if it results in delays, repeated contacts, additional workload for clinicians, or risks to patient safety,” said Victoria Tzortziou Brown, president of the Royal College of GPs.

Near misses and incidents 

There was evidence that A&G services had contributed to near misses and incidents of patient harm, both physical and psychological, where they had been poorly implemented or monitored. Harm included delayed or missed diagnoses and delays to care and treatment.

There were significant gaps between how some local A&G and single point of access (SPoA) processes had been implemented and national expectations. This included local pathways that required GPs to use A&G rather than making direct referrals, and referrals for specialist assessment being declined despite persistent clinical concern.

And issues with the NHS electronic referral service (e-RS), including interoperability problems and delays to planned system upgrades, made it harder to track patients through pathways and share clinical information consistently.

“Since its introduction, GPs have expressed deep concern with the advice and guidance system – we know our patients and know when a referral needs to be made,” said Clare Bannon, BMA GP committee chair. “So this report is tragic vindication for these concerns, now showing that patients have come to harm as a result of this rushed-out and inconsistently-applied process,” she added. 

The HSSIB has recommended that NHS England and the Department of Health and Social Care (DHSC) undertake a rapid evaluation of A&G services to address resource and capacity gaps, workforce training needs, e-RS digital risk management and weaknesses in patient safety incident reporting.

It has also recommended that NHS England and DHSC, working with relevant Royal Colleges, commission the development of standardised A&G request and response templates for specialities where these do not currently exist, and support their effective use in practice.