health

The Cheshire and Merseyside Consensus on the Primary Secondary Care Interface

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Imagine yourself in the following scenarios:

  1. You have an operation at the hospital and the surgeon tells you that you need to take 3 months off work sick. They provide you with a sick note (now called a fit note) for 2 weeks. When you ask if they can give you a note for the full 3 months they advise that you need to see your GP for that.
  2. You are waiting for an operation and attend the Pre-Operative Assessment Clinic (POAC) to check your medical fitness for an anaesthetic. You are known to have high blood pressure. Your blood pressure has not been checked by your GP for over a year, and when you attend the POAC your BP is found to be too high, your surgery date is put on hold and you are sent back to the GP to get the BP under control first.
  3. Some investigations are arranged by the hospital. You have the tests and are waiting for the results. You call the hospital to ask about them and they tell you that your GP should have access to the results and to go and speak to them. When you ask your GP about the results they say that as the hospital arranged the tests, you need to speak to them.
  4. Your hospital consultant tells you that you need a new medication and that they will write to your GP asking them to prescribe it for you. When you contact your GP they tell you that this is not a medication that GPs usually prescribe and that you need to go back to the hospital for this.
  5. Your GP refers you to a hospital consultant. When you are seen the consultant is puzzled as to why certain tests have not already been carried out by your GP as they are part of the agreed local pathway. No decision are made during your consultation as these test now need to happen first.
  6. You are referred to a hospital consultant. After seeing you they decide that your problem needs the input of a different specialist. They tell you that they will write to your GP asking them to refer you to them. When you approach your GP they tell you that they have not received any communication from the hospital yet, and will need to wait for this. They also imply that there was no reason why the consultant could not have undertaken this referral themselves.

If any of these things had happened to you, how would you feel? Frustrated? Annoyed and cross? Let down by the system? Confused perhaps? All of these scenarios are based on reality. I believe that patients are getting stuck in the gaps between services – at the interface between Primary (GP) and Secondary (hospital) Care. As you can see these are not just issues causing problems for the clinicians, they are causing delays and problems for patients.

I have been concerned about the Primary Secondary Interface for some years, but things really came to a head during the Covid-19 pandemic. At the time I was working as a GP advisor to the Cheshire and Merseyside Health and Care Partnership. GPs were being given a hard time by the press, and A&E departments were concerned that the increase in demand they were seeing might be related to perceived or real challenges in access to General Practice. I met with the Chief Executives of the hospitals across Cheshire and Merseyside to talk about the increases in demand that GPs were also seeing. It became clear that what we were all experiencing were pressures across the whole system. We were all working hard, we were all struggling to manage the demand.

I was asked to chair a ‘task and finish’ group looking at system pressures. As part of this we sent out a questionnaire to all doctors in both General Practice and Hospital settings asking them for suggestions of things we could do to ease the ‘system pressures’. We ended up with around 80+ suggestions of ‘quick wins’. At least a third of these related to issues at the interface between Primary and Secondary Care. We decided we would try and tackle this. Working with doctors across both Primary and Secondary Care we developed a document outlining the behaviours we would expect to see from colleagues. This was a list of high-level principles designed to help reduce work being passed unnecessarily between teams, and aimed at reducing bureaucracy and speeding up the patient pathway.

You can find our consensus document on this webpage: Primary and Secondary Care Interface – NHS Cheshire and Merseyside

Our consensus was agreed and published just before Integrated Care Boards (ICBs) went live a couple of years ago. We have continued to work hard since then to promote this within our system and encourage all clinicians to follow the principles within it.

We have learned much over the past couple of years about working at the interface, and continue to develop resources to help. That, however, is the subject of a future blog post!

I would encourage you to read our consensus and if you are working in healthcare you are welcome to consider using our consensus yourself, or better still using this as a basis for your own work.

Patients are being let down when they are passed around the system. It is better for us all when the interventions required are carried out by the most appropriate person or team as quickly as possible. This saves time for the patient and time for the system.

Dr Jonathan is a GP and Associate Medical Director, Primary Care, for NHS Cheshire and Merseyside

@DrJonGriffiths