Mastering the 2025/26 Advice & Guidance Enhanced Service: A Guide for GP Practices
The NHS continues to evolve, focusing on managing demand, boosting efficiency, and providing patient care closer to home whenever appropriate. Key goals include recovering elective services and redesigning outpatient pathways to cut down on unnecessary hospital visits - potentially saving millions of appointments annually.
Within this strategy, Advice & Guidance (A&G) services have become a vital tool. A&G enables GPs to connect with secondary care specialists for expert input before or instead of making a formal referral. This helps ensure patients get treated in the right place, supports shared decision-making, and eases pressure on hospitals.
While various A&G methods existed locally, the 2025/26 GP contract introduced the formal General Practice Requests for Advice & Guidance Enhanced Service (A&G ES). This follows the recent contract agreement aiming to bring stability to general practice. Backed by government focus and an £80 million funding pot specifically for e-Referral Service (e-RS) A&G use, this Enhanced Service signals a major push towards using specialist advice more effectively in primary care.
The £20 Incentive
A key part of the A&G ES is the £20 Item of Service (IoS) fee. Participating practices can claim this fee for each eligible pre-referral A&G request they initiate. This payment recognises the extra work involved for GPs when seeking specialist advice compared to making a direct referral. The goal is ambitious: to boost national pre-referral advice requests significantly, aiming for around four million in 2025/26.
Why This Guide Matters
This guide is designed for you – the GP Partners and Practice Managers navigating the new 2025/26 A&G Enhanced Service. We aim to provide the operational know-how and strategic insight needed to implement the service successfully. We'll explore how to maximise the benefits – including practice income, better referral quality, improved patient pathways, and enhanced clinical knowledge - while tackling the challenges like workflow changes, coding needs, workload impact, and patient communication. Let's dive in.
Understanding the Advice & Guidance Enhanced Service: Core Components
What Counts as "Advice & Guidance"?
The A&G ES focuses specifically on pre-referral advice. This means GP-led activity, not face-to-face, seeking specialist input for non-urgent (elective) patient cases before deciding whether to refer, or as an alternative to referral. It's about resolving clinical uncertainty.
This interaction can happen in real-time (like a phone call) or asynchronously (usually via the NHS e-Referral Service (e-RS) or other agreed local IT systems/email). It’s fundamentally a clinical conversation between the GP and the specialist about a specific patient.
The scope is broad, covering things like:
Guidance on treatment plans or managing a patient.
Help interpreting test results.
Advice on whether a referral is appropriate or if other pathways exist.
Help identify the best service for a potential referral.
It's important to note this is different from simple triage or a Referral Assessment Service (RAS). An A&G request under this ES requires the GP to actively consider and act upon the specialist's advice.
Signing Up: Your Practice's Commitment
Participation is voluntary for practices with GMS, PMS, or APMS contracts. However, to claim the £20 IoS fee, you must formally sign up.
How: Register via the Calculating Quality Reporting Service (CQRS) system.
Also: Record your agreement in writing with your Commissioner (usually the Integrated Care Board - ICB).
Deadline: Check the official deadline with your commissioner (an initial date of 27 May 2025 was mentioned, but confirm locally). Commissioners might allow later sign-ups.
By signing up, your practice agrees to:
Provide information reasonably requested by the Commissioner about the service.
Follow relevant guidance from NHS England.
Take reasonable steps to inform patients clearly about the A&G process.
Funding Deep Dive: The £20 Fee, National Pot, and Potential ICB Caps
The main incentive is the £20 IoS fee per eligible request. Remember: only one claim per distinct episode of care for a patient, no matter how many messages go back and forth on that specific issue. Good news: practices can claim retrospectively for eligible requests made since 1 April 2025, if they sign up promptly.
Nationally, £80 million is allocated for these payments. However, there's a crucial local factor: ICBs might cap the total number of A&G requests a practice can claim payment for.
This creates potential tension. While the national aim is high A&G usage driven by the fee, local caps could limit the financial incentive. High-using practices might hit their cap mid-year, reducing the reward for further A&G work. This could lead to inconsistencies across areas and might even discourage the very activity the policy promotes if caps feel too restrictive. You can still make A&G requests beyond any cap, but they won't attract the £20 fee. It's vital to get clarity from your local ICB about any caps.
Claim submission processes also need attention. Follow local guidance, but typically claims need prompt submission (perhaps within 12 days after the month ends). Note that while your practice gets the £20, the secondary care service providing the advice doesn't receive an equivalent national payment.
Implementing A&G in Your Practice: A Step-by-Step Guide
Develop Your Practice Protocol
A clear internal protocol isn't just good practice - it's required by the ES specification. This protocol should guide your clinical and administrative staff on using pre-referral A&G appropriately.
Include these key elements:
When to Use: Define clinical scenarios where A&G is the first step versus direct referral (referencing local pathways/ICB guidance).
GP Oversight: Specify how requests are reviewed and authorised by a GP before submission.
Identifying Patients: Outline how to spot patients who could benefit most (potentially linking to population health strategies).
Workflow: Detail how A&G fits into your consultation and admin processes.
Patient Communication: Include standard procedures and potentially scripts for explaining A&G.
Coding & Tracking: Outline the process for recording A&G activity accurately.
Make sure your protocol aligns with local requirements and available specialist advice channels. Review and update it regularly based on experience.
Communicate Clearly with Patients
Effective patient communication is essential and mandated by the ES. You must take reasonable steps to inform patients when A&G is sought and ensure they understand what it means.
Manage Expectations: Patients need to know A&G isn't a hospital referral itself, though one might follow. Explain it's a way for their GP to get quick expert advice on the best next steps.
Shared Decision-Making: Involve the patient. Explain why A&G is being considered, the benefits (faster input, avoiding hospital trips), and what happens next. Standard leaflets or scripts can help ensure clarity.
Address Concerns: Some patients might worry about delays or not seeing a specialist face-to-face. Explain the process, expected timelines (often a two working day target for responses), and that their GP remains in charge of their care. Providing clear, understandable information builds trust.
Prepare Your Team and Systems
Ensure your staff and systems are ready:
System Access: Clinicians initiating requests (GPs, potentially others if agreed locally) and admin staff processing them need correct system access. For e-RS, this means an active NHS smartcard with the right Role Based Access Control (RBAC) permissions.
Training: Assess training needs for:
e-RS Use: Creating requests, attaching documents, tracking, viewing responses, using the 'convert to referral' feature.
Practice Protocol: Ensuring everyone understands your internal process.
SNOMED CT Coding: Training on correct coding procedures (see Section V).
Admin Processes: Review and adapt workflows for generating, submitting (if admin supports GPs), tracking requests, and routing responses back to the responsible GP. Ensure systems support remote access if needed.
Optimising Workflow Integration
Clinical Workflow: Fitting A&G into Consultations
GPs need to identify suitable patients during consultations - those with non-urgent issues where specialist input could clarify things. Once identified, explain the A&G process clearly to the patient.
Crafting a good request takes time. The question needs to be clear, concise, specific, and include relevant clinical details. Using templates in your clinical system might help streamline this.
Be mindful of the time impact. While A&G aims for efficiency, the process of identifying, discussing, requesting, and actioning advice takes GP time. This needs balancing against potential time saved later. The £20 IoS fee is intended to compensate for this workload.
Administrative Workflow: Managing Requests, Tracking, and Follow-Up
Efficient admin support is vital:
Submission Support: Admin staff might assist GPs with the technical submission via e-RS (after GP review).
Tracking: Maintain a system (spreadsheet, log, clinical system feature) to monitor pending A&G requests. This is crucial for oversight.
Monitoring Responses: Actively check for specialist responses (target often two working days, but delays happen).
Chasing: Have a process for chasing overdue responses, using local escalation routes if available.
Actioning Responses: Ensure received advice promptly reaches the right clinician for review and action. Closing the loop is key.
A robust tracking system helps manage workflow, monitor usage, support quality improvement, and provides an audit trail for IoS claims.
Leveraging e-RS Functionality for Efficiency
When using e-RS for asynchronous A&G, make the most of its features:
Attachments: Attach relevant documents, images, ECGs, results (check file size limits: 5Mb per file via web, 5Mb total via integrated systems).
Dialogue: Use the two-way conversation feature for clarification if needed.
Conversion to Referral: This is a key efficiency gain. GPs can pre-authorise the specialist to convert the A&G request directly into a referral if appropriate. This saves GP time, avoids duplication, streamlines the patient journey, and ensures the receiving service has the full context. Encourage its use!
Historical Access: Access previous requests/responses within e-RS for reference (viewable for different periods depending on role).
Accurate Coding for Payment: SNOMED CT Essentials
Why SNOMED CT Coding is Critical
Accurate coding using SNOMED CT (Systemized Nomenclature of Medicine – Clinical Terms) is fundamental in modern general practice. It underpins reporting, population health, decision support, quality schemes (like QOF), and enhanced services.
Crucially for the A&G ES, accurate SNOMED CT coding is how eligible activity is identified for payment. Specific codes trigger payments via systems like CQRS. Correctly coding each A&G request according to the defined rules is absolutely essential to receive the £20 IoS fee.
Navigating SNOMED CT for A&G Claims: The Current Challenge
Here’s a major operational hurdle: the specific SNOMED CT codes needed to claim the £20 IoS fee under the 2025/26 A&G ES have NOT yet been officially published. Further guidance is expected from NHS England or your local ICB.
This ambiguity creates risk. Payment relies on correct coding, and claims can be made retrospectively to 1 April 2025. If you don't have a consistent way to record A&G requests now, retrospectively finding, verifying, and coding eligible encounters once the codes are announced could be incredibly difficult and time-consuming. You could miss out on legitimate income simply because the initial activity wasn't flagged properly.
What to Do Now (Even Without Official Codes):
Be proactive to mitigate risk:
Establish Interim Coding: Agree on a consistent internal method to flag A&G requests now. This could be:
Using a relevant existing SNOMED CT code (knowing it's likely temporary).
Creating a practice-specific template entry.
Using specific keywords in consultation notes for easy searching later.
Consult your local LMC for advice on suggested interim codes.
Maintain a Log: Keep a separate log (manual or electronic) of all A&G requests made under the ES. This is a vital backup for identifying claims later.
Focus on the Request: Ensure your interim coding/logging captures the act of requesting A&G, as this triggers the payment.
Waiting passively for definitive codes without tracking activity is operationally risky.
Data Extraction and Claiming
Typically, the General Practice Extraction Service (GPES) extracts coded data for CQRS payments. However, the exact claiming mechanism for the A&G ES (national GPES, local CQRS, manual?) needs clarification from your ICB. Follow their specific instructions on submission processes and deadlines. Accurate recording using the eventual SNOMED CT codes will be key.
Mastering Communication via e-RS A&G
Crafting Effective A&G Requests
The quality of your request impacts the response. Aim for clear, concise, informative requests:
Specific Question: Clearly state what advice you need. Avoid vague requests. (e.g., "Advice on optimal antihypertensive choice?", "Is cardiology referral warranted?", "Guidance on managing unresponsive eczema flare?").
Succinct Context: Include essential history, findings, results. Avoid long narratives. Structure it logically (Reason for Request, History, Exam, Investigations).
Relevant Evidence: Attach necessary items (ECGs, results, photos – crucial for dermatology). Ensure they are clearly labelled and pertinent. Check file sizes.
Indicate Urgency Appropriately: While non-urgent, provide context if timely advice affects immediate management.
Interpreting and Acting on Specialist Responses
Be ready for different responses:
Clear Guidance: A management plan, investigation ideas, or confirmation referral isn't needed.
Request for Information: Use the e-RS dialogue to provide more details if asked.
Advice to Refer: Specialist confirms referral is needed.
Conversion to Referral: If pre-authorised, the specialist converts the request directly (you should be notified).
Crucially, the requesting GP retains responsibility for reviewing the advice and deciding the management plan with the patient. If advice is unclear, seek clarification via e-RS dialogue. Document everything clearly in the patient record.
Best Practices for Attachments
Relevance: Only attach documents directly relevant to the question.
Quality: Ensure images/scans are interpretable.
Labelling: Use clear file names if possible.
File Size: Be mindful of limits (5Mb per file web / 5Mb total integrated).
Consent: Ensure appropriate patient consent for sharing information.
Navigating Challenges and Workload Considerations
Identifying and Mitigating Common Pitfalls
Anticipate potential issues:
Delayed Responses: Specialists face pressures too.
Suboptimal Advice: Vague or unhelpful responses can occur.
Workload Transfer: Concerns A&G might inappropriately shift work to primary care.
Disagreements: You might disagree with the advice on referral necessity.
Mitigation strategies:
Robust Protocols: Clear internal guidance.
Quality Feedback: Use local channels (LMC/ICB) for feedback on response quality/timeliness.
Escalation Processes: Use agreed local routes for persistent delays or poor responses.
Collaborative Relationships: Foster good communication with local specialists.
Uphold Clinical Judgement: A&G informs, but doesn't override, your judgement. Refer if clinically necessary based on professional standards.
Managing Workload Impact
A&G adds workload - identifying cases, discussing, requesting, tracking, reviewing, actioning. While the £20 IoS fee compensates, efficient management is key to prevent burnout.
This creates a workload paradox: a measure partly for system efficiency adds tasks locally. Its viability depends on whether benefits (better pathways, fewer complex referrals later, educational value, £20 fee) outweigh this burden.
Strategies to manage the impact:
Workflow Optimisation: Implement efficient clinical and admin processes.
Appropriate Delegation: Use admin staff effectively for tracking, chasing etc.
Template Usage: Speed up request generation with templates.
Dedicated Time: Consider allocating specific time slots for managing A&G.
Realistic Expectations: Acknowledge A&G needs dedicated time and resources.
Clinical Responsibility and Medicolegal Aspects
The requesting GP generally retains clinical responsibility until a formal referral is accepted or the episode ends. Acting on remote advice can feel exposed.
Mitigate risks with:
Thorough Documentation: Record the request, advice, patient discussion, rationale, and plan meticulously.
Adherence to Guidance: Follow GMC Good Medical Practice – refer when needed.
Clarity on Scope: Use A&G appropriately for non-urgent uncertainty, not as a substitute for needed assessments.
Addressing Potential Payment Caps
Remember the potential for ICB caps on paid requests.
Seek Local Clarity: Ask your ICB if caps apply, how they work, and how you'll be notified.
Financial Planning: Factor potential caps into income projections.
Monitor Activity: Track your A&G usage against any known cap.
Conclusion: Embedding A&G for Sustainable Practice
Key Recommendations
To successfully embed the A&G ES:
Engage: Sign up formally and promptly.
Protocol: Develop and implement a robust internal protocol.
Communicate: Establish clear patient communication strategies.
Optimise Workflow: Refine clinical and admin processes, leveraging e-RS.
Prepare for Coding: Use consistent interim recording now; adopt official codes immediately when released. Maintain a log!
Stay Informed: Follow definitive guidance from NHS England and your ICB (coding, claiming, caps).
Manage Workload: Plan realistically, use efficient processes and delegation.
Engage Locally: Talk to your ICB and specialists about pathways, quality, and caps.
The Future Outlook
A&G is positioned as a key part of NHS strategy and likely here to stay. Its success depends on widespread, effective implementation and genuine collaboration between primary care, secondary care, and commissioners. Ongoing monitoring of workload impact, advice quality, patient experience, and referral patterns is vital.
For general practice, mastering the A&G ES means managing the operational details while focusing on safe, effective, patient-centred care. It's one part of adapting to the evolving healthcare landscape, requiring continued efforts to ensure primary care remains sustainable and supported at the heart of the NHS.