Note: Some sections of this case study refer to clinical commissioning groups (CCGs). On 1st July 2022, integrated care systems (ICSs) took over statutory commissioning responsibilities in England, and CCGs were closed down. You can learn more about integrated care systems (ICSs) here.
Case study summary
The work on building relationships between the primary and secondary care interface has gone on for many years at Humberside. A combination of robust national policy and strong local clinical leadership has meant that the team has been able to make significant progress in the last few months, which resulted in a published agreement between colleagues.
The increasing workload in general practice and the resulting frustration for GPs was the trigger for commencing discussions locally. The appetite from colleagues in both primary and secondary care to better control their workload by streamlining patient journeys resulted in the positive dialogue that has been developed.
Despite inviting commissioners and secondary care providers across the Humber region, participation was not widespread, for a variety of reasons. There was, however, representation from clinicians and managers from two CCGs and one secondary care trust. Following eight months of deliberations, a document was agreed that primarily focused on:
- Local access policies (DNAs)
- Local access policies (onward referral of patients)
- Clinic appointments (expediting letters)
- Managing patient care and investigations
- Clinic letters & discharge summaries
- Medication requests
- Shared care protocols
- MED3 (Fit Notes)
- Follow up
- Communications with patient
Barriers and Challenges
Time and space
Finding time and space to facilitate a discussion across the interface when every single part of the NHS is trying to deal with more work with not enough resources.
There can be a reluctance to look beyond one’s own organisation and structures in developing solutions for the system.
Changing balance of commissioning and providing responsibilities of the medical profession.
The historic local access policies, which were considered to be unchangeable and not reviewed to facilitate decreasing workload and patient journeys.
Consistent implementation of existing and new policies and protocols
This is difficult especially in large organisations with changing, rotating and temporary staff as well as significant staff vacancies.
Whilst it has certainly made a difference in changing practices at an organisational level, and built relationships between commissioners and providers, the agreement was not expected to change practice overnight. The agreement provides a useful, locally-owned resource that has influence locally and which clinicians and the wider practice team can refer to in order to improve patient journeys and decrease workload across the system. This has been picked up by LMCs in various parts of the country who are looking to replicate similar discussions. The next round of discussions to build on the existing agreement is due to commence shortly. The expression of interest to engage with this work has now moved up from two organisations locally to all the NHS Standard Contract service providers in the Humber region and all four CCGs.
Local GP, Dr Andrew Green, developed a document that described how patient care pathways can be simplified to ensure that workload is not generated unnecessarily through the existence of complex pathways for care of patients between primary and secondary care.
Persistence from the profession
Local GPs’ determination to put a stop to unnecessary work by using the BMA’s Quality First templates.
The resources developed by the national primary/secondary care interface group (chaired by NHS Clinical Commissioners and including BMA GPC and CC, RCP, RCN, RCGP, AMRC, NAPP, NHS Providers, NHS Improvement and NHS England, resources are available to download.
The clinical chairs of Hull and East Riding of Yorkshire CCGs, Dr Dan Roper and Dr Gina Palumbo, along with the Medical Director of Hull and East Yorkshire NHS Trust, Mr Kevin Phillips, who were all determined to address this.
The second round of discussions will commence in July 2018 and focus on further improving the interface, with an expectation of an annual review of local arrangements. The agreements will be patient centric, with an emphasis on collaboration and educating patients and healthcare staff about patient journeys. There is definitely the local will and determination to see this through and the process will rely on the ongoing commitment and support from national organisations which is a key driver in promoting culture change and promoting collaborative working.
Dr Saskia Roberts, Medical Director, Humberside LMC firstname.lastname@example.org
Dr Krishna Kasaraneni, Medical Director, Humberside LMC email@example.com