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A&G is intended to give GPs access to specialist advice before making a planned referral, potentially allowing patients to be treated more quickly in primary care or avoiding an unnecessary hospital appointment. NHS policy continues to support greater use of A&G where clinically appropriate.

However, August has brought the most significant warning yet about how the model is being implemented.

On 18 August, the Health Services Safety Investigations Body (HSSIB) published an interim report finding evidence that poorly implemented or monitored A&G services had contributed to near misses, delayed or missed diagnoses, delays to treatment and patient harm. HSSIB said A&G can benefit patients but called for a rapid evaluation of the service before further expansion. The findings highlight a fundamental issue: who carries the clinical responsibility when a GP seeks specialist advice, but a patient is not subsequently referred? It has been previously argued that clinical risk should be shared between primary and secondary care, rather than falling solely on the GP.

This month, the Royal College of Physicians reported that the amount of A&G work being undertaken by hospital physicians is increasingly out of proportion to the time allocated for it in their job plans. Many doctors reported completing A&G work during evenings and weekends. Meanwhile, GPs have reported concerns that referrals are being returned to practices as unsolicited A&G. A survey reported this month found that GPs estimated around a quarter of their referrals were being returned in this way, although NHS England has denied that a 25% target exists.

For primary care, this raises an important distinction between using A&G to improve clinical decision-making and using it primarily as a mechanism for managing secondary-care capacity. The direction of travel towards greater use of A&G is unlikely to disappear and the more immediate question is the emerging safety concerns.

For primary care professionals, several issues will be important as A&G expands. Clear accountability will be essential, particularly around who is responsible for acting on specialist advice and ensuring appropriate patient follow-up. There also needs to be confidence that specialist responses are timely, with clear processes for what happens when advice is delayed or not received. A&G should support clinical decision-making rather than become a barrier to appropriate referrals where specialist assessment is required. At the same time, any additional workload transferred into general practice needs to be matched by sufficient time and resources. Robust digital systems will also be important to ensure requests, responses and subsequent actions are not lost between organisations. Ultimately, local A&G pathways will need to be monitored closely for patient-safety risks, including delayed diagnoses, inappropriate referral rejection and failures in follow-up.

The question is no longer simply whether GPs should use more Advice and Guidance, but whether the NHS can scale it safely and sustainably. The latest developments are an important reminder that reducing referrals is not the same as reducing the need for specialist care. If A&G is to become a central part of NHS referral reform, it will need to be supported by clear clinical accountability, adequate specialist capacity, robust digital pathways and genuine collaboration between primary and secondary care.

The success of A&G may ultimately be judged not by how many referrals it prevents, but by whether it delivers faster, safer and better-coordinated care for patients.