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NHS England’s internal forecasts suggest around 2.1 million GP cases were diverted into an “advice and guidance” pathway rather than a standard referral in 2023-24, HSJ understands.

This surpasses NHSE’s ambition for 2 million A&G cases and is more than three times as many as the 645,000 reported before the pandemic in 2019-20.

A&G involves GPs consulting specialists before making direct referrals and around half the time this results in a referral being avoided. The model, which has been the subject of rows between NHSE and primary care leaders is set to be a cornerstone of NHSE’s new outpatient transformation strategy

However, while national appetite for the model grows, there remains huge regional variation in the rate at which health systems are preventing patients joining the elective waiting list by using A&G.

Some systems – including Northamptonshire – have managed to ramp up these “diverts” to such an extent that they now report around one A&G case to every 3.5 cases cleared from the waiting list through treatment or seeing a consultant.

This contrasts with others, such as Lancashire and South Cumbria, which only reports one A&G case for every 16 cleared from the waiting list. You can read our full analysis here.

Referrals surge

Milton Keynes University Hospital Foundation Trust has seen a recent deterioration in its performance on long elective waits, falling towards the bottom of the table on the 65-week target.

Its chief executive says a “mind-blowing” increase in cancer referrals, and an unprecedented rise in all types of urgent ones, is behind this.

Joe Harrison says the trust has been getting 50 more referrals a day for cancer than before the pandemic. “We don’t know why we are seeing increases at this scale.”

He said: “We are doing all this extra work but we are not yet getting the traction on reducing routine waiting times because we have had to focus on urgent and emergencies”.

He suspects something greater than the impact of the pandemic is at play, as the rise has happened slightly too late for that, but it is thought population growth could be a key factor. Milton Keynes is one of England’s fastest growing cities, after all.

Mr Harrison said: “We are concerned it might be the new norm in terms of activity volumes.”

Cancer and urgent referrals to Milton Keynes and its integrated care system have indeed increased at a higher rate than the national average, compared to a few years ago.

Also on today

In Carbon Copy, Zoe Tidman asks whether the new central energy contract ties into a more sustainable health service, and in Comment, Raihan Mohammed says that as NHS operational priorities shift towards efficiency, quality metrics must not suffer.