Dr Andrew Foster: Introducing the Nottingham & Notts Primary-Secondary Care Interface Partnership

The Primary Secondary Care interface group has been working since 2021 to improve the way that staff at Nottingham University Hospitals and those working in General Practice work together.

Their focus is to improve patient care and clinical outcomes by strengthening relationships between these two groups of staff by building and trust and taking real action to change behaviours and processes that can complicate patient care and damage this partnership.

The group has delivered tangible changes, and the work of the group has been recognised locally and nationally with other organisations learning from their experience and working to create similar projects.

Key Achievements

The group has generated around 90 projects aimed at improving the interface between primary and secondary care. As a result, many of those things which have historically caused additional work and frustration should now happen much less often. Notable examples include:

• Hospital discharge summary audit – Over 7,000 discharge summaries have been audited to understand the type and scale of inappropriate transfer of work from secondary to primary care.
• Co-produced presentation outlining five asks that improve patient experience at the interface

The Five Asks Scheme   1. Communicate clearly and concisely. Where actions are required by the patient or GP, make this clear and easy to identify in all correspondence. 2. Refer a patient to another speciality within NUH where this relates to the original problem, or a directly related medical condition, rather than asking the GP. 3. Follow up the results of tests NUH have undertaken, informing the patient and completing any actions, as required. 4. Issue a fit note, wherever appropriate for the full duration needed. 5. Provide patients with prescriptions for new or altered medications when seeing them in an NUH outpatient setting

• Primary Care Presence in NUH Inductions – GPs now participate in junior doctor and consultant inductions, providing insights into the Primary Care perspective and fostering a culture of collaboration from the outset of their careers.
• Jointly agreed letter templates regarding inappropriate request to GPs – Templates agreed with and supported by NUH leadership to support General Practice to correct unsuitable demands.
• Primary-Secondary Interface event June 2024 – Attended by GPs and Consultants and supported NUH and the LMC to increase engagement with the work of improving relationships.
• NUH Fix It WhatsApp Group –
• No more “repeat chest Xray in 6 weeks” – An often-cited frustration in General Practice. Hospital staff now take responsibility for arranging repeat chest x-rays following discharge.

The Interface Group categorize their wide-ranging activity across six domains (Culture & Relationships, Continuous Improvement, Clinical Integration, Digital Integration, Training and Development and Communications) and have a pipeline of future improvement plans.

How the Primary Secondary Care Interface Group began and evolved

The relationship between Secondary Care clinicians and General Practice is complicated. Many have felt historical frictions worsen in recent years as demands on the system have increased and technology, standardised communication proformas and referral triage processes have increased the distance between the two sectors.

This interface work began in late 2021, as both General Practice and NUH were facing huge pressures due to the COVID19 pandemic. All Nottingham based clinicians share the care of a population experiencing broad challenges including; access to care, worsening outcomes, and health inequalities. The system faces large backlogs of pent-up demand and long waiting lists, a workforce exhausted by pandemic pressures, and significant financial pressures.

A group of NUH consultants, staff and leaders from General Practice began meeting to explore how the two sectors could collaborate and work more effectively together to meet these challenges.

Early discussions in the interface group identified the sense of a deepening “them and us” culture. Initial meetings allowed clinicians from both sectors to express their struggles candidly and acknowledge that they were facing similar and connected issues. This transparency has been crucial in the developing of relationships, trust and a culture of collaboration.

There was a shared recognition that both primary and secondary care were struggling with similar challenges. They became focussed on finding solutions that benefit both sectors and also securing a smoother journey through the system and better outcomes for patients.

Principles

A focus on early quick wins allowed the group to build momentum, grow and become an established fixture within the system. The group has expanded to include representatives from NUH clinical and organisational leadership, Nottingham City and South Notts Place Based Partnerships, the ICB Clinical Design Authority and Nottinghamshire LMC.

Representatives from NUH departments and other parts of the system attend meetings to discuss specific issues relating to their part in the interface between primary and secondary care. They meet weekly to discuss challenges and to address issues.

People involved

A culture of open, honest, informal communication and relationship-building enables an agile approach to making decision and taking action. The work is supported by the NUH integration team who support the structure and governance of the group. This has been essential to balance the open and informal atmosphere with an ability to be organised and impactful.

Primary/Secondary Roadmap

The group has delivered multiple milestones since 2021, these include:

September 2021	Primary/Secondary Care Interface Group established to support the recovery of Long Term Conditions management
October 2021	Explored initial areas of focus including UEC attends and Spirometry
August 2022	Primary Care video incorporated into Junior Doctors Induction
September 2022	Shared Learning Programme commenced (3 year multi disciplinary rolling training programme jointly provided by NUH Heads of Service and Primary Care
November 2022	1st Primary/Secondary Care Working Group with NUH CEO and Primary Care Representatives
November 2022	Spirometry Pilot Launch
November 2022	Flu outreach pilot commenced providing opportunistic vaccinations to patients attending routine hospital appointments
January 2023	Established a Written Communications Sub Group to look at clinic letters/discharge letters/waiting list communications/TTO audit
January 2023	NUH CEO writes to all GP practices to share the Trust’s first People First Report
May 2023	2nd Primary/Secondary Care Working Group with NUH CEO and Primary Care representatives
August 2023	Written Communications Group engagement with 45 specialties to feedback issues raised by interface group and identify opportunities for improvement
September 2023	Audit of 7,000 TTOs to review what is being asked of GPs
October 2023	Reinforcement of clinical and professional behaviours enabling improvement of the interface
November 2023	Primary/Secondary Care update to NUH Trust Leadership Board
December 2023	NUH Fix IT Pilot commenced
January 2024	Primary/Secondary Care Interface Update to NUH Trust Board
January 2024	Echo on ICE business case approval
January 2024	GP/Consultant Twinning Scheme – 20 NUH Consultants and 20 GPs shadowing one another to gain broader understanding of each other’s environments
May 2024	Primary/Secondary Care Working Group meeting with NUH CEO and Primary Care Representatives
May 2024	NUH Chief Executive writes to all GP practices
May 2024	Raising the profile of this work locally and nationally through various routes including ICB, NHS England and NHS Confederation
July 2024	Primary/Secondary Care Engagement Event

Learning from the Interface Group

The impact of this work has led to increased interest from clinical specialties keen to engage with the interface group. There have been discussions exploring the establishment of groups to improve the interface between other system partners such as Nottinghamshire Healthcare Trust and East Midlands Ambulance Service. The initiative has gained recognition at a national level, with group leaders being asked to share learning from the Nottingham experience through the NHS Confederation.

Key learning points Building Relationships and Trust: Regular informal meetings where leaders create an open and safe culture enabling representatives from both sectors to engage in candid discussion about mutual concerns. Adaptability and Flexibility: Being open to change and to challenge established norms, behaviours and embedded processes. Audit activity and use data: The group audited over 7,000 discharge summaries from NUH to understand the type and scale of work transfer from secondary to primary care, such as requesting further tests and referrals. This evidence added credibility to calls to change processes and behaviours. Commitment from senior leaders: Senior clinical and executive leaders from both sectors champion the work of the group with colleagues. Leaders need to have sufficient credibility and influence with colleagues to make the argument for change. Support with governance and structure: To ensure that meetings are productive and actions are completed. The NUH interface team provide project management to ensure that projects are delivered and meetings function effectively.

How to feedback clinical issues to NUH

What already exists?

• Via E-Healthscope
• Emailing the dedicated inbox: nuhnt.gp.feedback@nhs.net

What is on the horizon?

• Implementation of the Five Asks Scheme template letters – available on F12/Ardens [expected November]

For more information, to learn how to get involved, or to suggest an issue for the group to address, please email nuhnt.integrationteamnuh