A new strategy in England could seek a significant reduction in GP referrals – but it will need cooperation from primary care, it has emerged.

The proposals are being developed by senior officers at the Royal College of Physicians for NHS England and would see a big increase in the use of “advice and guidance”. This would require an on-line conversation between a GP and a specialist, potentially involving the patient, before a referral was confirmed. The working group is also studying potential ways for patients to “navigate their own way” to secondary care, it emerged.

The Royal College of GPs said there are concerns in some areas where it is in use that it is being used to mask waiting list pressures.

Speaking to the Health Service Journal, Dr Theresa Barnes, outpatient lead at the Royal College of Physicians, said: “I think there should be a push to use advice and guidance in preference to direct referrals, so we can maximise that pre-referral interaction and deliver as much care as close to patients’ homes as they can get it and without the delay of potentially waiting for a secondary care appointment.”

Dr Barnes added: “We can make the advice and guidance conversations at least visible to patients and sometimes invite their input into the conversation. We have been exploring self referral for new patient appointments, which may be an interesting idea for the future. This already exists in some clinical areas like genitourinary medicine, where they have an established pathway. But we are trying to explore whether for all conditions at all times ‘do we need to have a gatekeeper? Is the GP the right gatekeeper or can the patient navigate their own way to specialist care?’”

Dr John Dean, RCP clinical vice-president, told the HSJ the new systems would have to ensure doctors in both primary and secondary care have the time to undertake advice and guidance. He said it “has to be jointly commissioned between primary, secondary care professionals and patients.”

RCGP chair Professor Kamila Hawthorne said that in some areas advice and guidance is being used “as a barrier to artificially protect waiting lists and prevent patients getting the care they need” . GPs are then left with a “spillover” of referrals delayed or rejected, she said. She said the system had the potential to work well.