Purpose of this guidance

It is intended to support LMCs and practices where A&G systems are not functioning as intended or are creating inappropriate workload or barriers to referral.

NHS England continues to promote the use of A&G to reduce pressure on secondary care and reduce referrals into hospital services. Under the 2026/27 GP Contract, the £80 million A&G funding (uplifted to £82 million) has been incorporated into the core GP contract funding.

This change does not remove the ability of GPs to refer patients for specialist care.

However, NHS England expects Integrated Care Boards (ICBs) to identify their top ten specialties and ensure that by 1 October 2026 these specialties operate via a Single Point of Access (SPoA) model.

LMCs should be involved in the development and implementation of local systems relating to A&G and SPoA.

Key messages for practices

• GPs retain the ability to refer patients for specialist assessment where this is clinically appropriate. Advice and Guidance (A&G) systems must not prevent or inappropriately delay referrals.
• Single Point of Access (SPoA) systems are intended to streamline referral pathways but do not override the GP’s clinical decision to refer.
• Advice and Guidance should support clinical care, not be used to deflect referrals, or transfer unfunded work into general practice.
• GPs must work within their competence. Where specialist input is required to provide safe care, it must remain accessible.
• Jess’s Rule highlights the importance of reconsidering diagnoses when patients present repeatedly with unresolved symptoms.
• Local Medical Committees (LMCs) should be involved in the development and implementation of SPoA pathways and any arrangements that may transfer workload into primary care.
• Where referrals are inappropriately returned as Advice and Guidance, practices may wish to respond formally and retain correspondence in the patient record

The GP’s role and the ability to refer

GPs are independent clinical decision-makers and retain the professional responsibility to refer patients for specialist assessment where this is clinically appropriate.

Preventing or obstructing referral may place doctors in conflict with their professional obligations under Good Medical Practice, which states that doctors must:

“Refer a patient to another suitably qualified practitioner when this serves the patient’s needs.”

Further GMC guidance on delegation and referral is available on the GMC website.

This principle is also supported by the NHS Constitution, which protects patient choice in accessing specialist care.

Advice and Guidance systems should therefore support clinical decision-making rather than act as a barrier to referral.

Single Point of Access (SPoA

SPoA systems are intended to provide a single digital entry point for referrals and clinical enquiries.

NHS England describes SPoA as a mechanism to:

• Route all clinical enquiries and referrals through a single access point
• Enable shared clinical decision-making between primary and secondary care.
• Provide timely access to senior specialist advice.
• Reduce unnecessary administrative complexity.

NHS England states that SPoA does not override the GP’s decision to refer but aims to ensure that once a referral decision has been made the patient is directed to the most appropriate service.

For primary care, SPoA should:

• Provide a transparent route to specialist input.
• Offer clear response times.
• Enable early access to specialist advice where community management may be appropriate.
• Reduce avoidable administrative burden once referrals are submitted.

Following SPoA triage, the outcome may include:

• Allocation of an outpatient appointment
• A request for additional clinical information
• Advice and Guidance regarding investigation or treatment
• Redirection to a more appropriate specialist service

Development of SPoA Pathways

Pathways developed to operate through SPoA must include appropriate stakeholder engagement.

LMCs, as the statutory representatives of general practice, should be involved in pathway design and implementation.

Pathways should also be supported by appropriate commissioning arrangements where workload shifts into primary care.

Appropriate use of advice and guidance

The General Practitioners Committee England (GPCE) is clear that A&G may be used as a supportive clinical tool, but must not be used to:

• Delay appropriate referrals.
• Deflect referrals inappropriately.
• Prevent patients accessing specialist assessment where clinically required.

A&G systems should not undermine the GP’s role as the patient’s clinical advocate.

Clinical responsibility and Jess’s Rule

Jess’s Rule highlights the importance of reconsidering diagnoses where patients present repeatedly with unresolved symptoms.

Clinicians are encouraged to reconsider the diagnosis if a patient presents three times with the same symptoms or concerns, particularly where symptoms:

• Persist unexpectedly.
• Escalate
• Remain unexplained.

In such circumstances clinicians should review and reflect on the diagnosis and management plan, and where clinically appropriate consider further investigation or referral for specialist input.

Jess’s Rule was developed following the death of Jessica Brady, who died from bowel cancer after repeated presentations in primary care.

Clinical safety and professional limits

Clinical safety and professional limits must be respected in the use of A&G.

The General Medical Council (GMC) states that doctors must work within the limits of their competence.

Further GMC guidance can be found on the GMC website. 

GPs should not be expected to manage conditions that:

• Require specialist expertise.
• Fall outside their clinical competence.
• Cannot be safely managed with available primary care resources

Where specialist input is required to provide safe care, this must be accessible without unreasonable barriers.

Patients also have the right to request referral for specialist care.

Avoiding unfunded workload transfer

Advice and Guidance must not be used to transfer unfunded workload into primary care.

Requests for the following should align with locally agreed commissioning arrangements:

• Investigations
• Monitoring
• Initiation of specialist treatments

Primary care should not be asked to undertake work requiring specialist expertise unless this has been formally agreed, commissioned, and appropriately resourced.

LMCs should be involved where workload shifts into general practice are proposed.

Documentation and accountability

All Advice and Guidance interactions should be clearly documented within eRS.

Where pathways involve shared care or A&G processes, the clinical responsibility at each stage must be clearly defined.

Clear documentation supports clinical safety and medico-legal accountability

Referrals via eRS and SPoA

SPoA via eRS is expected to become the primary route for referrals in the identified specialties from October 2026.

Where a GP requires specialist assessment rather than advice, the referral should clearly state that the request is for a specialist consultation.

If a referral requesting a consultation is returned with Advice and Guidance instead, practices may respond to clarify that the request was for a referral rather than advice.

Acceptance and rejection of referrals

The NHS Standard Contract states:

“The Provider must accept any referral of a service user made in accordance with the referral processes and clinical thresholds set out in this Contract or otherwise agreed between the parties, and where necessary to enable a service user to exercise their legal right to choice as set out in the NHS Choice Framework.”

Further information can be found on NHS England's website.