BADGER

When a primary care clinician (such as a GP) needs a specialist’s (usually a consultant) input with the care of a patient, one option is to use Advice and Guidance (A&G). A&G is an electronic way for a clinician in primary care to ask a specialist a clinical question, who provides a response, usually within a few days. The response may be to send an appointment for the patient to see a specialist, try a treatment, or do a test. A&G was introduced to speed up access to a specialist opinion and cut waiting times for outpatient care. A&G became more important during the COVID-19 pandemic as it meant patients did not automatically need to travel to hospital. The use of A&G is now encouraged to help the NHS recover from the pandemic. There are very few studies telling us whether A&G has a better or worse effect on patient care than the usual referral system.

We will study the impact of Advice and Guidance on patients, healthcare workers and the healthcare system, in terms of: 

• how often, why and when A&G is used
• views about its impact on the quality of care and patient satisfaction
• impact on how NHS services are used. 

This will help us to work out whether A&G reduces waiting times and access to specialist care as planned, without making the quality of patient care worse. This will be done in comparison to the more traditional way of referring patients to be seen by a specialist in outpatients.   

Part one will describe how A&G is being used in the NHS. We will use a national database of anonymous GP records to find patients who have A&G requests in their notes. We will describe the patterns of A&G use since 2015 to work out whether some patients are more likely to have A&G versus usual traditional referrals (for example, older patients or patients from certain ethnic and socioeconomic backgrounds). We will interview GPs to ask about how they use A&G and if they think it helps patients or not. We will use these interviews and patient data to work out which specialties we should look at in more detail.

Part two of the study will focus on how well A&G works. We will use a national database of anonymous GP records and hospital records to work out if there are differences in what happens to patients who see a specialist in hospital through A&G versus usual referrals. What we will measure will be informed by Part 1, but may include issues such as time to cancer diagnosis, admissions to hospital, further GP visits, other referrals, and treatments. This will help us to report if, overall, A&G impacts on the quality and use of care. 

Part three of the study will focus on the experience of A&G from the perspectives of patients, specialists and commissioners (health care leaders). The interviews will take place over the course of the study period and use the findings from Parts 1 & 2.

In Part 4 we will work with professionals who use A&G and members of the public about our key messages and how best to talk about them, with the aim of improving understanding about the use of A&G and overall patient care.

We will include patient views at each stage of the study through a patient and public involvement group and a patient applicant on the study team. We will ask about which specialties to include, what outcomes to look for and other factors we might need to think about in the analysis. Working together with patients, we will produce information about the most important findings from our study that can be shared in ways that will reach patients and the public. 

This study/project is funded by the NIHR Health and Social Care Delivery Research (HSDR) Programme (NIHR158681). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.