Trends and inequalities in Advice and Guidance versus direct referral in NHS primary care

Objective: to examine trends and variation in the use of Advice and Guidance (A&G) compared with direct referrals in primary care, and to assess potential disparities across population groups. Design: Observational study using routinely collected electronic health records Setting: Clinical Practice Research Datalink (CPRD) Aurum, 2015-2023. Main Outcome Measures: annual prevalence of A&G and direct referrals, stratified by age, gender, deprivation, locality, and ethnicity. Mapping of clinical codes was used to determine target specialities for A&G. The proportion of individuals recorded with A&G and a direct referral within ±4 months was calculated. Results: Between 2015-2023, 671,894 patients (4%; 59% female) had A&G recorded and 9.7 million (59%; 46% female) had a direct referral. A&G use increased 19-fold from (0.10% to 1.97%), doubling between 2019 and 2020 during the COVID-19 pandemic. Direct referral rates fell from 23%-25% pre-pandemic to 18% in 2020 before recovering to 24% by 2023. Cardiology (21%), Dermatology (7%) and Ear, Nose and Throat (5%) were the most common specialties linked to A&G. Most patients receiving A&G (86%) also had a direct referral within ±4 months. Inequities were evident: A&G use was higher among older, white, and less deprived patients, while minority ethnic and more deprived groups had slower recovery of direct referral rates post-pandemic. Conclusion: A&G use has increased substantially since 2015, accelerated by the pandemic and maintained after, but has not displaced direct referrals. Instead, direct referral often precedes A&G, raising questions about efficiency and equity. The system appears to benefit older, white, and less deprived individuals while minority ethnic and more deprived groups remain disadvantaged. Policy should prioritise addressing these disparities and evaluate whether A&G reduces unnecessary referrals or delays access to specialist care.