NHS referral failures have been linked to patient deaths, delayed cancer diagnoses and other harm, according to a new investigation by England’s healthcare safety watchdog. The Health Services Safety Investigations Body (HSSIB) is calling for an urgent review of the Advice and Guidance system before it is expanded further across the NHS.
The warning affects patients in England whose GPs seek specialist hospital advice through Advice and Guidance (A&G), a system intended to help doctors decide whether a patient needs a hospital appointment or can be managed without one.
HSSIB said the service can work well and give patients quicker access to specialist advice. However, its interim report, published on Tuesday, 18 August, found that poor implementation, delayed responses and problems with electronic referral systems had contributed to missed or late diagnoses and delays to treatment.
Patients who are waiting for care should seek medical advice again if their symptoms change or become worse. NHS 111 can provide urgent advice where the situation is not life-threatening, while patients should call 999 in a medical emergency.
HSSIB warns of deaths and delayed cancer diagnoses
HSSIB examined incidents involving the A&G system and found evidence of both physical and psychological harm.
Its investigation identified cases involving delayed or missed diagnoses, a poorer cancer prognosis, avoidable surgery and patients suffering symptoms for longer than necessary.
One case involved a patient with epilepsy who went to a GP after suffering repeated seizures. The GP sought specialist neurological advice, but no response was received for a month.
An urgent referral was then made but was not dealt with for more than six weeks. While waiting for the referral to be assessed, the patient suffered another seizure at home and died following a cardiac arrest.
A coroner concluded that the patient died from sudden unexpected death in epilepsy and cited several factors affecting the person’s care, including delays involving the A&G request and subsequent referral.
HSSIB’s wider evidence review also identified a separate case in which a patient died while waiting for cardiology treatment after a delay in reviewing investigation results. The watchdog recorded A&G as a factor that may have contributed to the actual or potential harm identified in that group of incidents.
The report does not conclude that the A&G system alone caused the deaths.
Melanoma found more than six months later
Cancer cases raised further concerns.
In one example, a GP repeatedly tried to refer a patient to a specialist because of suspected skin cancer. HSSIB said the referrals were described as having to pass through a mandatory A&G process and specialists responded with advice based on a photograph.
The patient was eventually seen more than six months later and diagnosed with melanoma. By that stage, the cancer was more advanced than when the GP first raised concerns.
Another patient was being investigated after blood was found in their urine. A urology A&G request was converted into a hospital referral, but the referral was accidentally cancelled during processing without the patient or GP being told.
Six months later, the patient sought further medical help and was diagnosed with endometrial cancer requiring major surgery.
HSSIB said it found evidence of A&G being used in some pathways where GPs had sought specialist assessment for suspected cancer, contributing in some cases to diagnostic delays.
National NHS policy, however, states that urgent suspected cancer referrals should not be replaced by Advice and Guidance.
Referral system should not be used to block patients
Advice and Guidance allows a GP to seek advice from a hospital specialist before, or sometimes instead of, making a planned hospital referral.
HSSIB found significant differences between the way some local systems operated and what NHS England intended.
Investigators found examples of local pathways requiring GPs to use A&G rather than make direct referrals. There were also cases where requests for specialist assessment were declined even though the GP continued to have clinical concerns.
NHS England has stressed that the system is not supposed to be used to reject or refuse hospital referrals.
Its guidance says the clinical threshold for referring a patient has not changed and a GP’s clinical judgement remains central. Where a GP receives specialist advice but still believes a hospital referral is necessary, there should be a clear route for the patient to be referred.
NHS England also says there is no national target requiring a fixed percentage of referrals to be diverted away from hospitals.
Some specialist responses delayed for months
HSSIB found that most specialist responses were made within expected timescales, but there were repeated examples of patients waiting weeks or more than six months for responses.
NHS England’s operational standard says specialist A&G requests should normally receive a response within five working days. Routine referrals should also be actioned within five working days, while urgent referrals should receive a next step within two working days.
Problems were also found with the NHS electronic Referral Service, known as e-RS, including difficulties connecting it with other NHS IT systems and problems tracking patients through the referral process. HSSIB said planned upgrades had also been delayed when its report was prepared.
The watchdog said the full scale of the patient-safety risk could not currently be determined because some incidents, particularly those identified in general practice, were not consistently recorded in the national patient-safety reporting system.
NHS planning wider referral changes from October
The findings come as NHS England moves towards greater use of A&G and Single Point of Access (SPoA) systems.
Under NHS plans, providers are expected to introduce elective SPoA arrangements beginning with 10 priority specialties, with wider implementation planned from October 2026. The model brings referrals and specialist advice requests through one digital route so they can be clinically reviewed and sent to the appropriate service.
HSSIB said it supports the benefits of A&G where the system is properly designed, staffed and monitored. Doctors told investigators that good services could provide quicker specialist input, shorten waits and prevent unnecessary hospital appointments.
But the watchdog is now recommending that NHS England and the Department of Health and Social Care carry out a rapid evaluation before further expansion.
The review should examine staffing and capacity, workforce training, digital risks, oversight and weaknesses in reporting patient-safety incidents. HSSIB also wants standard templates introduced so GPs and hospital specialists provide clearer and more consistent information when seeking or giving advice.
Senior HSSIB investigator Dr Nick Woodier said the system was making a difference for many patients but investigators had also found “evidence of harm” where services had not been properly designed or monitored.
The findings put renewed pressure on NHS leaders to ensure attempts to cut unnecessary hospital appointments do not create new barriers for patients who genuinely need specialist treatment.
