Why Primary Care Clinicians use Advice and Guidance: A qualitative study

Abstract Background Advice and Guidance (A&G) enables primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs’ decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Topic guides were developed with PPIE input and refined iteratively. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Analysis Four overarching themes encapsulate clinicians’ decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care. How this fits in (<4 sentences) Advice and Guidance (A&G), introduced in 2015, enables primary care clinicians to obtain specialist input for patients within elective care pathways without initiating a formal referral; the proposed 2026/27 GP Contract aims to expand or mandate its use in line with the NHS ten-year plan and strategic efforts to move more care from hospitals into the community. Our findings suggest clinicians decide to engage with A&G when they can expect timely, high-quality responses that support safe management of sometimes clinically complex patients. Primary Care Clinicians are also sensitive to the risks of inappropriate transfer of workload from secondary to primary care, clinical responsibility for conditions traditionally managed in secondary care, and associated costs into primary care, and that these concerns directly influence their willingness to use A&G. Ensuring that electronic A&G systems support transparent, two-way communication and maintain visibility for both primary and secondary care teams may therefore improve usability and sustain clinician engagement.