By Dr Ben White, Case Team Lead

Since the introduction of NHS Advice and Guidance members have been contacting Medical Protection with concerns about the medicolegal risk of using this system, particularly since NHS England announced that Advice and Guidance was to form part of the GMS contract this year and followed this up with a letter in April clarifying the purpose of the initiative and setting out further information on the operational standards to expect.

Members have concerns about liability and what they should do if they do not agree with the decision that has been made following their referral into the system.

Relevant exchange of information

When utilising Advice and Guidance, it is essential that primary care clinicians include all necessary information to enable the responding clinician in secondary care to decide on the most appropriate management. Equally, should the responding clinician note that there is information that appears to be missing that might influence their decision (e.g. details of the presence or absence of certain red flags), that clinician should seek this information from the referring clinician.

Duty of care

The referring clinician’s duty of care does not end at the point they send their referral or request Advice and Guidance. The referring clinician will maintain a duty of care to their patient, for example ensuring that any relevant change in symptoms, or deterioration in condition, is communicated to secondary care. Referring clinicians should also ensure advice is provided so patients know what to do in the event of a change in their condition.

Practices may wish to consider having a system in place for ensuring that they have received a response in a timely manner having made a referral or requested Advice and Guidance.

On receipt of Advice and Guidance it is very important that this information is clearly documented in the patient’s record and discussed with the patient. Patients must be provided with good safety netting advice so that they know when to seek help should their condition not be following the anticipated course. This safety netting advice should also be clearly documented.

The responding clinician in secondary care also has a duty of care to the patient and has a responsibility to ensure that the decision they make on whether to offer Advice and Guidance to a referrer, or to see the patient face to face (including time frames for review), is appropriate.

Secondary care organisations will ideally have a clear and appropriate set of timescales for responding depending on the urgency of the request. Ideally there should be a clear process for referring clinicians to raise a concern if they believe the decision made in secondary care is inappropriate, to avoid any delays that might otherwise be caused by this process.

When responding to the referring clinician with Advice and Guidance, this should be confirmed in writing and be detailed in such a way that it is unambiguous regarding next steps in patient management.

Liability

Ultimately, where liability lies if something goes wrong where Advice and Guidance has been used, will be dependent on the specific details of the case. This will include where any negligence is alleged to have occurred during the Advice and Guidance pathway, for example, whether all the relevant details were provided by the referring clinician and whether this was acted on appropriately in secondary care.

Disagreement about recommended management

Where the referring clinician disagrees with the proposed management, for example, where a referring clinician feels that a patient needs to be seen face to face in secondary care but Advice and Guidance is provided instead, it would be advisable for the referring clinician to raise this directly with the secondary care clinician and decide on the best approach together.

Raising concerns

If a primary care or secondary care doctor is concerned that patient safety is being put at risk owing to the Advice and Guidance process, or has concerns about how the process has been implemented, then they should consider raising concerns in line with their local policy and the GMC Guidance.

With the changes to the GMS contract this is clearly a developing area and one that Medical Protection will keep under review.

Medical Protection members with specific queries about the changes in referral systems and/or the use of Advice and Guidance can contact us for advice.