Keep it local – developing Primary Secondary Care Interface Groups

I have been producing a series of blogs about the Primary Secondary Care Interface. In Cheshire and Merseyside we have been working to improve this interface and reduce instances of patients finding themselves stuck between services.

The kind of things I am talking about are where patients are told that the hospital cannot provide a sick note, directing patients to their GP, or where GPs fail to follow locally agreed referral pathways. When the interface breaks down, the patient loses out, and we create additional work for our colleagues.

We have produced a Consensus Document and a Communications Toolkit, both of which can be found on our website here: Primary and Secondary Care Interface – NHS Cheshire and Merseyside

The consensus and supporting comms toolkit are high level. They describe principles which we believe individual clinicians should be following. These principles, if followed, should result in improved pathways for patients and reduced system-generated work and demand. There are some things that the consensus will not sort out for you though.

• While the consensus asks GPs to ‘check local pathways’ it does not specify what they are, or what they should be.
• When a patient attends A&E, has an X-ray and is sent home, but a subsequent formal report says that a repeat X-ray is required in a few weeks – who should arrange that? The consensus will not tell you.
• When something is found on an X-ray or scan that does not relate to the presenting condition, the consensus does not really tell you who should deal with this.

All of the above require local work to ensure appropriate pathways are in place, and that everyone understands and uses them.

My suggestion would be, for these details, to Keep It Local.

We have created local Primary Secondary Care Interface Groups (PSCI Groups). These are largely formed around the footprint of the local Acute Trust, but also cover Mental Health and Community Services.

I think PSCI Groups are where the real interface work needs to take place.

At a recent NHS Confederation webinar I was part of, colleagues from Primary and Secondary Care in Nottingham gave an inspiring presentation demonstrating what they are doing with regard to the interface. They were getting buy-in from both GPs and Consultants, reaping the benefits. One of their advantages was that they were doing this around a single hospital footprint.

At a local level you can identify the issues and rapidly create solutions and new pathways. This is much harder if you are trying to do it across a large ICB area (we have 16 Trusts in our ICB).

My recommendations for a functioning PSCI group would be:

• Use a geographical footprint that makes sense to you
  • This might be around a single hospital Trusts, or a couple (or more) in a local area.
  • If you can get more than one hospital in the room that will help. They can act as peer-support, but also provide peer-challenge.
• Make sure you include Mental Health Trusts and ideally Community Health Trusts
  • Interface issues don’t only exist with Acute Trusts
  • Remember that your Mental Health Trust may need to engage with more than one PSCI group (and potentially several)
• LMCs need to be involved.
  • They represent the views of local GPs and will be a good source of intel from the practices.
• While the Medical Director of the Trust needs inviting, you may want to also invite any deputy/associate medical directors.
  • They may be the ones ‘doing the doing’ within the hospital.
• See if you can get the Hospital Chief Operating Officer or their deputy.
  • There are logistical issues that will need to be addressed and the COO can unlock this for you.
  • Changing clinical behaviours can be helped by managerial colleagues putting in enablers and removing barriers.
• Identify your issues, but work on relationships.
  • As per my recent blog(s) we have to understand each other better, and these issues are more easily solved when relationships are strong.

Fundamentally within your PSCI group you want to nurture a quality improvement culture. You need to move from tackling individual concerns and complaints, to thinking about the whole system, and developing your relationships along the way.

If your local area does not appear to have a local PSCI group, perhaps now is the time to think about setting one up.

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