Is Advice and Guidance Safe?

A patient died waiting for A&G responses. This is what went wrong.

HSJ reported today that the Health Services Safety Investigations Body (HSSIB) has called for a rapid evaluation of NHS England's Advice and Guidance policy before any further expansion, following a review that linked poorly implemented A&G pathways to patient harm, including two patient deaths.

A patient with epilepsy waited over six weeks after an urgent referral went unanswered before dying of a cardiac arrest. And a patient with suspected skin cancer had several referrals returned with advice only; when eventually seen more than six months later, a melanoma was diagnosed and was more advanced..

These are not administrative failures. They are the consequences of clinical pathways that were not monitored, not resourced, and not designed with the safety controls needed to catch cases falling through the gaps.

We want to be direct about what we believe the HSSIB findings mean, and what they don't.

What the HSSIB found

HSSIB's report, according to HSJ's reporting, does not say Advice & Guidance is wrong. It says that poorly designed and inadequately monitored implementation is contributing to harm. HSSIB senior safety investigator Nick Woodier specifically noted genuine enthusiasm for A&G where it is working well, while making clear that the risks of poor implementation are real and must be addressed before further rollout.

The investigation identified several failure modes. A&G requests going unanswered for weeks or months with no alert or escalation. Referrals inadvertently cancelled on eRS with neither the patient nor GP informed. A "mandating effect" in some areas where all referrals were being forced through A&G regardless of clinical appropriateness, contrary to NHS England's stated intention. Significant gaps between national guidance and what was actually happening on the ground.

These are implementation and management problems, and in most cases preventable ones.

Why this matters for how A&G is designed and run

Advice & Refer, done well, is genuinely better for patients. A specialist who can resolve a clinical question before a patient is added to a waiting list, in minutes rather than weeks or even months, is providing faster and more appropriate care. 

What the HSSIB findings make clear is that the evidence for the model does not transfer automatically to every implementation. The cases HSSIB identified were not primarily about A&G happening too quickly. They were about A&G not happening at all, with no mechanism in place to detect that and act on it.

It’s important for every ICB and trust currently planning or expanding A&G pathways ahead of the October 2026 requirements to understand that. The question is not whether to do Advice & Refer. It is whether the infrastructure around it is capable of making sure every case gets a response in time, and that no patient falls out of the system without anyone noticing.

What safe implementation actually requires

The cases HSSIB describes share a common thread: absence of oversight. Requests submitted with no mechanism to detect non-response. Referrals cancelled with no notification to the referrer or patient. Pathways operating without the monitoring needed to catch the cases they were missing.

Safe Advice & Refer implementation requires more than a digital form.

Automatic escalation. When a case has not been responded to within a defined clinical timeframe, the system needs to flag it to the specialist team, a clinical lead, and where necessary the referrer, before harm occurs rather than after. Waiting for a GP to follow up is not a safety mechanism.

Complete audit trails. Every case, at every stage, should be visible to the people responsible for oversight, as part of the live clinical workflow rather than a separate reporting system someone has to remember to check. The ability to see every open case, its status, and how long it has been waiting is what makes systematic monitoring possible.

Outcome tracking. Whether a case was resolved with advice, converted to a referral, or returned without a clear outcome should be recorded and reviewable. Where patterns emerge, a particular pathway generating high return rates or a particular specialty with consistently slow response times, those patterns should be visible to commissioners before they become safety incidents.

Pathway appropriateness controls. The mandating effect HSSIB identified, where all referrals were being forced through A&G regardless of clinical need, is a governance failure as much as a system design failure. The platform supporting A&G needs to enable clinicians to escalate directly where the clinical situation warrants it, without being blocked by a mandatory process that does not fit the case in front of them.

Patient communication. When a case is reviewed and an outcome reached, patients should be informed promptly rather than left waiting on a letter or a GP callback that may not come. Where local agreements allow, direct patient notification removes a meaningful source of both anxiety and unnecessary follow-up contact with practices.

The implementation problems HSSIB has identified are solvable

HSSIB's finding that national guidance on A&G is not translating into safe local practice will not surprise anyone who has worked on referral pathway design. Policy and practice diverge in the NHS constantly, and A&G is no different.

More national guidance will not fix this. Implementation that builds the safety controls in from the start will, rather than treating oversight as something to add once a pathway is already running at volume.

Cinapsis was designed with these controls as core features. Every case that enters the platform is tracked from submission to outcome. Unresponded cases trigger automated alerts. Clinical leads have real-time visibility of pathway performance. Referrers are notified of outcomes, and nothing closes silently without a record. These features exist because a high-volume clinical pathway operating without that oversight is exactly the scenario the HSSIB report describes, and exactly what led to the harms it identified.

What should happen now

HSSIB has recommended a rapid evaluation of A&G processes before further expansion. That recommendation deserves to be taken seriously and acted on quickly, not as a reason to slow the adoption of Advice & Refer as a clinical model, but as a prompt to ensure that every existing and planned implementation has the safety infrastructure it needs to function properly at scale.

For ICBs and trusts currently reviewing their A&G pathways ahead of the October 2026 SPoA requirements, the HSSIB findings warrant a direct assessment: what happens in our system when a case goes unanswered? Who knows about it, and how quickly? What is the escalation pathway?

If those questions do not have clear answers, they need them before any further expansion happens.

One part of that answer is clinical safety assurance before a pathway goes live, not after. Cinapsis follows a structured clinical safety process for every deployment. Before any A&G pathway is activated, we complete a DCB0129 clinical safety case (documenting the risks associated with the system and the mitigations in place) and require customers to complete a DCB0160 as the receiving organisation, confirming that risks have been understood, assessed, and addressed locally. 

This means that by the time a pathway is live and managing real patient cases, the safety groundwork has already been done. It is not something retrofitted once problems emerge.

That approach is what the HSSIB report points toward: safety by design, with documented accountability, before volume builds.

If you are reviewing your Advice & Refer or SPoA implementation and want to understand how Cinapsis supports clinical safety oversight, get in touch with our team. You can also read more about what good A&R implementation looks like in practice, and why the referral pathway matters for patient outcomes.

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