Trends and inequalities in advice and guidance versus direct referral in NHS primary care, 2015-23: population based study.

Objectives: To examine trends and variation in the use of advice and guidance compared with direct referrals in primary care, and to assess potential inequalities across population groups. Design: Population based study. Setting: Clinical Practice Research Datalink (CPRD) Aurum, an anonymised UK primary care database, 1 January 2015 to 31 December 2023. Participants: 16 340 696 patients with electronic health record data registered in CPRD; 671 894 (4% of the registered population) had advice and guidance recorded and 9 719 796 (59% of the registered population) had a direct referral recorded. Main outcome measures: Annual prevalence of advice and guidance, and direct referrals, in each calendar year, grouped by age, sex, social deprivation, locality, and ethnic group. Mapping of clinical codes to determine target specialities for advice and guidance. Proportion of individuals recorded with advice and guidance and a direct referral within ±4 months. Results: 16 340 696 registered patients were analysed between 2015 and 2023; 671 894 patients (4%) had advice and guidance recorded and 9.7 million (59%) had a direct referral. Use of advice and guidance increased 19-fold from 0.10% to 1.97% of the registered population, doubling between 2019 and 2020 during the covid-19 pandemic. Direct referral rates decreased from 23-25% before the 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 advice and guidance. Most patients receiving advice and guidance (86%) also had a direct referral within ±4 months. Inequities were evident: use of advice and guidance was higher among older, white, and less deprived patients, whereas minority ethnic and more deprived groups had slower recovery of direct referral rates after the pandemic. Conclusions: The study showed that the use of advice and guidance has increased substantially since 2015, accelerated by the covid-19 pandemic and maintained after, but has not displaced direct referrals. Direct referral often preceded advice and guidance, raising questions about efficiency and equity. Use of advice and guidance was higher among older, white, and less deprived individuals, whereas minority ethnic and more socially deprived groups were more likely to have direct referrals after advice and guidance, suggesting potential delays in access to specialist care. Policy should prioritise dealing with these inequalities and evaluate whether advice and guidance reduces unnecessary referrals or delays access to specialist care.