Building an evidence base for the use of Advice and Guidance Referrals at the primary-secondary care interface: multistage mixed-methods study

Background: Advice and Guidance (A&G) was introduced in NHS primary care to reduce waiting times for elective care and improve access to specialist input without the need for an outpatient referral. However, its impact on care pathways and equity remains unclear, especially for underserved populations.

 

Approach: This mixed-methods study included analysis of 16.3 million patients’ primary care electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum (2015–2023) to compare trends in A&G and direct referrals stratified by demographic factors (age, gender, deprivation, ethnicity, and commissioning locality).

Qualitative interviews with 20 primary care clinicians explored decision-making around A&G use, analysed using reflexive thematic analysis.

Patient and public involvement (PPI) contributors were involved throughout: co-applicant roles, protocol development, topic guides, and interpretation of findings. Community conversations with seldom-heard groups informed dissemination and equity framing.

 

Results: Recorded A&G use rose 19-fold (0.1% to 2.0% of the registered population) from 2015 to 2023, peaking during the pandemic. Direct referrals fell in 2020 but recovered to 24% of the registered population receiving a referral in 2023. Cardiology, dermatology, and ENT were the most common A&G specialties. Most patients receiving A&G (86%) also had a direct referral within ±4 months - often preceding A&G - suggesting A&G adds steps rather than replaces referrals.

Disparities were evident: A&G was recorded more frequently for older, white, and less deprived patients, while minority ethnic groups experienced slower recovery in referral rates. Regional variation was substantial, but higher A&G use did not correlate with reduced referrals.

Interviews revealed four key influences on A&G use: patient presentation, clinician experience of using A&G, balancing potential patient benefit with clinician workload, and the clinical need for specialist input. Clinicians valued A&G for supporting the management of patient with complex clinical needs and navigating unclear boundaries between primary and secondary care, but raised concerns about service availability, transfer of costs, and inconsistent policies.

PPI contributors shaped the study’s equity lens, identified barriers such as digital exclusion and transport, and co-produced dissemination materials.

 

Implications: A&G has not displaced direct referrals and may introduce inefficiencies. Its disproportionate use among advantaged groups risks widening health inequalities. To align with NHS goals of integrated, equitable care, A&G processes should consider efficiency across systems, routinely monitor for equity, and be supported by investment in primary care capacity. These findings offer transferable insights for international delegates exploring digital referral systems, outpatient reform, and strategies to reduce access disparities.