The government's chosen “milestone” to deliver in health care is to bring down waiting lists and restore the NHS constitutional standard for 92% of people to start specialist treatment within 18 weeks of referral. This pledge follows a sustained increase in the waiting list, rising since 2012, and which accelerated during the Covid-19 pandemic.
A key policy to achieve this is “advice and guidance”, where hospital specialists provide advice to GPs to enable them to manage the patient without an onward referral to hospital – stopping patients from joining the list in the first place.
Increasing use of advice and guidance was a strong priority in the 2022 elective recovery plan for planned care. This Labour government then set out to supercharge it, with the introduction of payments to GPs and higher targets. Now we can look back at whether this push for a faster roll-out succeeded and whether or not, in turn, it has kept patients safely off waiting lists.
Where did the model come from, and how does it work?
The NHS has a long history of initiatives to constrain the number of people coming onto the waiting list and to reduce referrals from GPs. Over a number of years, local areas have operated advice and guidance models, ranging from informal arrangements between specialists and GPs (such as email advice lines), to structured processes commissioned for specific services (see box below). In 2020, NHS England identified advice and guidance as one of the interventions which could enable the NHS to recover planned hospital treatments more quickly during the pandemic, and the national electronic referral service was enhanced to support it.
The 2022 elective recovery plan introduced consistent national rewards for hospitals reducing referrals from GPs through advice and guidance schemes, over and above locally agreed levels of activity and payment. Diverted requests – where the patient was not added to the waiting list – could be counted towards acute trusts’ target for outpatient activity to qualify for elective recovery payments.
In April 2025 an incentive was introduced for GP practices, which currently receive £20 for requesting advice and guidance for a patient who has not yet been referred. 1 This was intended to drive more growth in advice and guidance – providing more widespread support to patients in the community where appropriate, rather than referring them to hospital care and putting more pressure on patient waiting lists. It is hoped that this will deliver 4 million advice and guidance requests from GPs in 2025/26, including 2 million requests diverted from elective care.
However, the £20 payment per request to GPs is now set to be scrapped, announced this week as part of the new GP contract. Instead, it will be embedded into core funding for practices.
What is advice and guidance and how does it operate in practice?
Advice and guidance can include:
- asking another clinician or specialist for their advice on a treatment plan
- asking for clarification regarding a patient’s test results
- seeking advice on the appropriateness of a referral
- identifying the most clinically appropriate service to refer a patient to.
The current NHS model aims to increase advice before a referral, but outpatient clinical teams also triage referrals and can provide advice to the GP without seeing the patient.
Different local models for advice and guidance have been established, usually at a specialty level within a hospital. Examples include:
- Local arrangements for GPs to contact specialists using an agreed process or at specific times, such as “speak to the registrar models”.
- A collaborative model for menopause care, combining referral reviews with a shared formulary, improved patient information and streamlined protocols for some conditions.
- Developing a dedicated consultant rota for advice and guidance in a hospital neurology service, in collaboration with primary care commissioners. This is supported by brief guidelines for the management of common conditions. The service enabled more patient treatments to be informed by specialist advice; the number of outpatient appointments did not decrease.
- Advice and guidance supported by sharing digital images in dermatology (teledermatology) is widely used in the NHS and is the primary referral route in a number of services.
Will the government meet its ambitions to increase advice and guidance?
The number of advice and guidance requests have increased year on year. The latest reliable data is from November 2025, and suggests that progress still falls well short of the target to achieve a total of 4 million requests by the end of next month (March 2026). In order to reach the target, we would expect around 15,800 requests to be processed for every working day of each month, but so far, advice and guidance activity is on average only reaching around 12,800 per working day. In absolute terms, nearly 2.2 million requests have been processed so far, leaving 1.8 million to still be made before the end of March if the target is to be reached.
Similarly, the number of diverted requests per working day is currently far behind reaching the 2 million target. Just over 7,900 diverted requests would need to be achieved per working day, but the current trend shows that the numbers lie between 6,000 and 6,600. In total, there were just over 1 million diverted requests recorded two-thirds into the financial year, with roughly 940,000 more diversions needed to meet the target.
Note: The Department of Health and Social Care has told us by correspondence that they see these aspirations - variously described as targets or expectations for an increase "to up to" 4 million and 2 million - as "ambitions", which did not imply a full commitment to deliver the exact number. (added 03/03/2026)
Although the overall number of requests has increased, the proportion of requests that were diverted has been slightly lower in 2025/26 than previous years (on average 49% for the months from April to November, compared with 51% from April 2022 to March 2025). This could be due to GPs making more advice and guidance requests through the new incentivised payments introduced in April last year, but fewer are being diverted as a proportion of this total.
The total number of diverted advice and guidance requests between April and November 2025 increased by 18% relative to the same period in the previous year, compared to a 13% increase between 2023 and 2024. While requests have increased year on year, the change in incentives in April 2025 does not appear to have led to a surge great enough to currently meet the advice and guidance targets.
Has advice and guidance made a difference to referral activity?
A stated aim of the policy to incentivise increased use of advice and guidance is to ultimately reduce the number of new patients joining the elective waiting list. While advice and guidance can achieve other benefits for patients, by enabling treatment decisions to be made more rapidly in primary care, it is important to examine whether the increase in advice and guidance has resulted in a reduction in referrals.
The number of referrals has continued to increase, although more slowly than diverted requests (see chart below). Referrals from April to November 2025 were 3% higher than in the same period in 2024. Diverted requests increased by 18% over the same period, so it is possible that some diverted requests are substituting some referrals – as envisaged by the government’s ambition – but referrals are not going down because underlying demand is increasing at a greater rate.
It is also likely that some diverted requests may never have resulted in a referral by a GP (if the GP did not consider there would be a benefit to the patient from a referral), but the wider roll-out of advice and guidance is leading to more requests for advice to be made or recorded.
What can we learn from variation in use of advice and guidance across specialties?
Advice and guidance is already more well established in some specialties than others. Variation between specialties in uptake of advice and guidance can illuminate the extent to which there is further scope for expansion of the programme – or whether it is already being well used in appropriate clinical areas.
Trauma and orthopaedics and ear, nose and throat specialties have longer waits for planned care than average, and alone make up a fifth (20%) of the total waiting list. In contrast, specialties such as cardiology and dermatology – for which uptake of advice and guidance is much higher – account for a lower proportion of the waiting list (11%).
While there are some differences in the growth of advice and guidance across specialties, the pre-existing pattern remains: growth has continued in specialties where the use of advice and guidance is already relatively high. In specialties where advice and guidance is not already established, the extended policy is not, as yet, leading to much growth in its use.
Increasing use of advice and guidance in a specialty might be expected to reduce outpatient activity. However, data on this activity for selected specialties shows that since the Covid-19 pandemic (when disruptions caused activity to plummet), appointments have steadily increased for all specialties, albeit at different rates. Any reductions that may have been brought about by advice and guidance were obscured by a general upward trend in outpatient activity.
Conclusion
Although advice and guidance requests and diversions have continued to increase since the policy change in April 2025, there is no indication that the policy has led to a more rapid increase in advice and guidance than might have occurred anyway. Based on activity to the end of November 2025, it is unlikely that the target of two million diverted requests by next month (March 2026) will be achieved. Yet introducing payments for general practices to submit these requests will have already cost an estimated £43.5 million, and this still only counts requests made in the first two-thirds of the financial year.
Diversions are increasing more slowly than requests, indicating that it is becoming more difficult to reduce referrals through the scheme. This could be because local and informal arrangements are already operating, and there is a limit to what more can be achieved in some organisations or specialties. In other words, the benefits of advice and guidance are already ‘baked in’ to activity patterns.
Requests and diversions have increased in specialties which already had high rates, and established ways of working, such as dermatology and neurology. Several specialties where patients are waiting longest, and in larger numbers – such as trauma and orthopaedics and ear, nose and throat – have so far shown limited advice and guidance activity. This suggests that some specialties are inherently less likely to be appropriate for advice and guidance.
In specialties or hospitals where there has been limited use of advice and guidance, changes to the policy may not yet have had time to translate into greater use of advice and guidance: this needs buy-in from clinicians in primary and secondary care, and changes to clinical and administrative processes.
Changes to using the electronic referral system might also not automatically lead to increased advice and guidance, although reporting may become more consistent. In areas such as teledermatology, there are often established local systems in place, which might be disrupted in the short term by a move to using a standardised approach.
In conclusion, it doesn’t seem that advice and guidance will be the silver bullet that the government might be hoping for to reduce waiting lists – and perhaps it’s not a surprise that financial incentives for GPs have been scrapped. Used well, advice and guidance has the potential to quickly get patients the answer they need, preventing them from having to wait for months, and therefore deliver more efficient care. It may also be bringing other benefits, but as yet there is no systematic evaluation of the policy.
As we know from evaluating patient-initiated follow-up (PIFU) – another flagship programme to reduce outpatient activity – implementing change in patient pathways takes time, may not bring about the benefits anticipated, and may well be suitable for some clinical areas but not others. It will be important that the latest advice and guidance scheme is evaluated to understand where it is achieving benefit, wider impacts, such as on clinical workload, and how it could be improved.