Safety Watchdog Calls for Pause on NHS Referral Scheme After Deaths Linked to Delayed Care

The Health Services Safety Investigation Body (HSSIB) has called for an immediate pause in the expansion of NHS England's Advice and Guidance referral scheme after identifying links between the policy and the deaths of at least two patients. The watchdog's findings, which also cite a number of near misses, delayed treatments and missed diagnoses, mark the most serious challenge yet to a scheme NHS England has built into the centre of its elective recovery strategy.

Advice and Guidance was designed as a triage mechanism allowing GPs to seek specialist input electronically before making a hospital referral, rather than sending every patient straight to an outpatient appointment. Rather than a face to face consultation, requests are reviewed asynchronously by hospital consultants, who can advise on management in primary care, suggest further tests or downgrade a referral altogether. The scheme has existed for roughly a decade, but its scope widened sharply after the pandemic, and from April this year NHS England made it mandatory across ten specialties under new GP contract terms, retiring the enhanced service that had allowed direct referral to consultants.

The safety concerns identified centre on delay and drift. Investigators found that diagnostic and treatment delays occurred in conditions where time matters most, including suspected cancers, as communication and monitoring within the A&G pathway broke down. The incorrect downgrading of referrals is another issue. In certain trusts, routine GP outpatient questions are transformed into A&G cases without adequate professional supervision, transferring patient management to primary care without the specialised assessment that a face-to-face recommendation would have guaranteed. Underlying both findings is a more structural problem: inconsistent tracking systems and unclear accountability between primary and secondary care clinicians, which the investigators say allowed higher risk patients to fall through gaps between organisations rather than being caught by either side.

The findings do not stand alone. The British Medical Journal has stated since before the April rollout that senior GPs feared the obligatory system would delay care and undermine clinical autonomy. The Care Quality Commission has independently pressed NHS England and other organisations for answers on eleven different safety issues related to the scheme's expansion. Some trusts, including in Croydon and Nottingham, have already set up informal channels with local GPs to flag referrals that specialists have rejected, an improvised safeguard that suggests formal tracking has not kept pace with the policy's reach.

The watchdog's recommendations point toward a more rigorous, if slower, version of the scheme: a rapid formal evaluation, defined safety thresholds, mandatory tracking of referrals as they move between primary and secondary care, and explicit governance over who holds clinical responsibility for a patient at each stage. None of this is incompatible with the underlying aim of reducing unnecessary outpatient appointments, but it does imply that the pace of the rollout has outstripped the infrastructure needed to run it safely.

For NHS England, a pause would complicate an elective recovery plan already under scrutiny on cost and delivery grounds, and would test the credibility of a policy ministers have championed as evidence that demand on hospitals can be managed without simply expanding capacity. For GPs, who have carried much of the anxiety about clinical responsibility since the scheme was made mandatory, it offers some vindication, though not yet relief. NHS England has not indicated whether it will accept the call to pause expansion, and the response from ministers and professional bodies representing GPs and hospital specialists is likely to shape how quickly, if at all, the scheme's rollout is reconsidered.