Aug 23, 2026 9 min read

Cowper’s Cut 444: Is A&G making the primary-secondary interface more aggy?

Innovation slang in languages is a good thing: it keeps them alive and evolving. ‘Verlan’ does this for French, and like Cockney rhyming slang, it dates its roots back to a nineteenth century ‘cant’ or ‘cryptolect’: a code-language within professional groups, intended largely to mystify outsiders (the French professional group in question being robbers, where Cockney rhyming slang is thought to have emanated from market traders).

Younger people today keep the English language vigorous with abbreviations like ‘cossi-lives’ (cost of living) or ‘Platty Jubes’ (for the late monarch’s Platinum Jubilee).

I’m fond of ‘aggy’: the widely-used contraction for ‘aggressive’: helpfully, it works for this week’s theme, which is the revealed unintended consequences of the NHS England-mandated policy of using the new GP contract to push Advice and Guidance between GPs and secondary care.

A new survey of 712 GPs from Pulse finds that over a quarter of attempted referrals by doctors were rejected and returned as unwanted “Advice and Guidance” that the GPs had not requested. This included rejections for patients referred for red-flag suspected cancer symptoms, which clearly raises the chances of these patients not being seen within the two-week NHS fast-track cancer treatment deadlines.

Pulse also reports that their survey found the responding GPs “were waiting ten days on average for secondary care to respond to A&G requests, despite hospital trusts being required to respond to GP A&G requests within five working days. GPs also estimated more than a third (36%) of A&G they received included tasks outside their remit as a GP.

Hospital doctors’ doubts on A&G

“Meanwhile, a recent Royal College of Physicians survey found seven in 10 physicians said they received requests they believed were ‘inappropriate’ for the A&G route ‘including some that require urgent clinical intervention’ …

“The RCP’s survey also found that physicians who deliver A&G felt they often do not have enough allocated time to do so, with nearly half of the respondents (47%) reporting they had no dedicated time for A&G written into their job plan. It revealed 89% of physician respondents had received no formal training on delivering A&G, despite 67% saying they did deliver A&G.”

NHS England’s official position, which the Pulse story reflects, is to deny that any 25% A&G target exists.

Mmmmmmm.

And the expansion of A&G forms a key part of NHSE’s RTT waiting list reduction plan (such as it is).

As RTT waiting list specialist Dr Rob Findlay’s latest Health Service Journal column observes, “unreported removals from the referral-to-treatment (RTT) waiting list increased in June, reaching levels normally associated with ‘validation sprints’. The surge was big enough to stop the waiting list from growing, but not nearly enough to put the headline figures on track for 18 weeks recovery.

“Over the past five years (and since the Covid shutdowns), unreported removals from the RTT waiting list have averaged 14 per cent of total removals. (NHS England published a thorough explanation of removals and unreported removals here.) Unreported removals comprise any change in the waiting list that cannot be explained by the other data.

“When they increase suddenly, it is usually a sign that NHS trusts have stepped up efforts to remove patients who are on the waiting list in error (for instance, because they were treated some time ago, but were not correctly removed from the waiting list).”

There is no 25% national A&G target: not even for ready money

NHSE National Director for Primary Care and Community Services Dr Amanda Doyle’s April 2026 letter to primary care states, “there have been concerns about the terminology used in the recently published neighbourhood health framework, in particular that SPoA can contribute to a diversion rate of at least 25%.

“But is important to be clear that there is no national target (original emphasis) for specialists, trusts or general practice to divert a fixed proportion of referrals away from hospital care. The objective is simply to identify the most appropriate next step for each patient, based on specialist assessment and triage at speciality or sub-specialty level.

“The (25%) figure quoted relates to an estimate of the potential proportion of patients, including those who are the subject of an A&G enquiry, who could be appropriately assessed and supported by a specialist consultant without a hospital outpatient appointment. It is not the proportion of referrals to be sent back to general practice.”

NHS England gave the following quote to The Times, which followed up the Pulse story: “while Pulse acknowledges that this survey, which offered a £500 prize, is not scientifically representative of GPs, the simple truth is that A&G is a well-established and successful way of giving patients earlier input from an expert consultant, while still allowing them to be seen in hospital if needed.”

HSSIB: stop further A&G rollout for re-assessment

Health Service Journal was given exclusive early access to the judgment of the Health Services Safety Investigations Body, which orders a rapid review of the A&G initiative. It said: “HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of [A&G] processes …

“Completing this evaluation and addressing findings before further expansion of advice and guidance processes, including as part of single point of access, would ensure risks to patient safety have been identified, assessed, and managed.”

HSSIB is acting now, and pre-publicising its findings to HSJ, on its evidence of A&G causing clinical harm. As HSJ reports, the forthcoming HSSIB assessment documents “include strong support for A&G where it is working well. But its report says poorly-designed or badly-monitored implementation elsewhere is contributing to harm. This includes delayed and missed diagnoses, including in cancer care”.

Significantly, the HSSIB findings shared with HSJ describe an A&G “mandating effect” in some areas, with commissioners and providers requiring all referrals to first be sent for A&G, despite NHSE insisting this was not the intention. HSSIB told HSJ that this was linked to changes to the 2026-27 GP contract.

Here are the key problems: assuming that the RCP survey is representative, then A&G provision among hospital doctors is not being properly resourced. And we know this since NHS leadership has now spent some years trying to get doctors’ job planning taken seriously. If A&G responses in hospitals are not being adequately resourced, this is obviously going to cause delays and cost GPs’ confidence in the system.

There is not necessarily much such confidence. We are living through a very low-trust period of the English NHS: one in which staff goodwill can (rightly) no longer be seen as part of the core psychological contract between system and staff.

I went through all of this in some detail.

Clearly, we cannot yet be certain how big a role A&G diversion or delay is playing in the RTT and non-RTT waiting backlogs. But it will become more apparent with every month’s data.

Equally clearly, if patients who meet widely-accepted clinical thresholds for urgent referral do not get urgently referred, then the job of treating them once they are eventually diagnosed becomes harder, more expensive and worse all round.

Another key problem: it’s a short distance from A&G to A&E. If GPs become aware that A&G is being used as an insufficiently-safe waiting list workaround (even if it is not intended as such), then they will certainly change their referral strategy. This is unlikely to be a positive outcome.

As Professor David Haslam has long pointed out, primary care has always been the main risk-sink of the English NHS. David’s first-rate 2023 book ‘Side-Effects: How Our Healthcare Lost Its Way And How We Fix It’ can be found here.

A&G is clearly a useful tool, as Dr Mark Porter’s balanced column for The Times outlines. But like any system tool, it needs to be resourced to do the job it is expected to do. Playing ‘pass the parcel-bomb of clinical risk’ with an underdeveloped A&G policy is not a smart move.

Bigger is better, right until it isn’t

In my last column, I slightly missed out a sub-aspect of one of the big three themes that will be dominating the English NHS health policy and politics scene for the next few years. That important subset of the ‘centralisation vs. decentralisation’ dialectic is this: what happens to all the bad mergers?

I first became interested in the subject when I wrote up this HSJ roundtable on mergers and acquisitions, back in 2013. Those were days. The wildly unsuccessful 2009 mega-merger that created South London Healthcare Trust out of three poorly-performing and loss-making NHS provider trusts was nearing the end of its time as the first NHS trust put into administration, before its breakup later on that year.

I later had a ringside seat when I did some communications work chronicling the takeover of Heart of England NHS Foundation Trust (itself previously metastatised by a merger with serial failure and first commercial management franchisee Good Hope) by the then-high-performing University Hospitals Birmingham Foundation Trust. UHB’s takeover of HEFT was done at the behest (i.e. begging) of FT regulator Monitor: it was certainly responsible for significantly increased pressure on the UHB leadership.

Recent ambient noise about problematic merged trusts won’t have escaped most ‘Cut’ readers’ attention. This week brought the news in HSJ that three Midlands hospital trusts are unravelling their de facto merger of a ‘shared chair and CEO’ arrangement. University Hospitals of Leicester formed this hospital group arrangement in 2023 with the “University Hospitals of Northamptonshire Group”, which had already combined Kettering General Hospital and Northampton General Hospital trusts in 2020.

Professor Naomi Fulop’s academic work confirms what many of us know: that splicing together numerous NHS provider organisational turkeys does not magically create an eagle. Any ‘phoenix’ effect of a rebirth requires a genuine merger - i.e. takeover by the dominant and more successful culture - to be enduring. Most do not make it: organisational cultures die hard, even (and perhaps especially) bad ones.

As I wrote in last week’s column, there is a huge unresolved tension in English health policy between the impulses and legislation towards centralisation of power in the Department For Health But Social Care, and the Mascara/Manchesterism political vogue for decentralisation.

This tension can probably be ignored for a while, and so it probably will be: the danger is that nobody is thinking seriously about what the English NHS model of operation and improvement should be, and thus where the incentives need to be put.

Hospital doctors’ doubts on A&G

There is no 25% national A&G target: not even for ready money

HSSIB: stop further A&G rollout for re-assessment

Bigger is better, right until it isn’t

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